The signs of stress: Embodiments of biosocial stress among type 2 diabetic women in New Delhi, India

Highlights

• A biocultural exploration of diabetic Indian women's mental health.

• Diabetic Indian women report normative mental health, despite poor glucose control.

• Biomarkers confirm that physical health is compromised, but stress is controlled.

• Qualitative inquiry finds that women maintain key gender roles, despite illness.

• Maintenance of gender roles may buffer women's mental health, yet compromise diabetes control.

Abstract

Biocultural models of health and illness are increasingly used to trace how social pathways shape biological outcomes. Yet, data on the interactions between social and biological aspects of health are lacking in low- and middle-income regions, where two-thirds of all type 2 diabetes cases occur. This study explored health, social roles, and biological correlates among a group of 280 type 2 diabetic and non-diabetic women (n = 184 diabetic) in New Delhi, India, between 2009 and 2011. Using a biocultural framework, we developed and tested a series of hypotheses about the relationships that might exist between diabetes, psychological distress, social role fulfillment, and biological markers measuring blood sugar control, generalized inflammation, and immune stress. Although blood glucose and glycated hemoglobin levels indicated that women's diabetes was generally poorly controlled, they lacked the elevated inflammation, immune stress, and mental ill health that often accompany uncontrolled blood sugar. Qualitative work on explanatory models of diabetes and gendered models of appropriate behavior demonstrated that despite living with poorly controlled diabetes, women maintain participation in culturally valued roles involving the care of others. We suggest that behavioral congruence with these gendered roles may buffer diabetic women's mental health and perhaps even their long-term physical health, while simultaneously posing challenges for their diabetes self-care. To our knowledge, this is the first study to explore the experience of type 2 diabetes in India from an integrated biocultural perspective.

Introduction

It is by now a truism that chronic and noncommunicable diseases are the largest causes of adult mortality in the world, and thus constitute key health challenges for our collective future (Yach et al., 2004). Yet, chronic diseases continue to increase in prevalence around the world, including in India (Joshi et al., 2008, Mohan et al., 2006). Many reasons for this difficulty have been proposed, including the complex etiologies and long durations of chronic diseases, as well as their contingency on non-medical (that is, cultural, social, and structural) factors (Worthman and Kohrt, 2005).

This study, based in New Delhi, India, uses a biocultural theoretical framework to explore the embodied experience of type 2 diabetes. Specifically, it aims to integrate Indian diabetic women's understandings and experiences of type 2 diabetes (hereafter, “diabetes”) with biomarkers of physical and mental health. The goal was to assess women's physical and mental health status, obtain qualitative and quantitative information about the degree to which diabetes impinges on women's everyday lives, and determine how gendered social roles might shape the pathways between diabetes and poor physical and/or mental health.

A remarkable 66 million people are estimated to have type 2 diabetes in India; this constitutes over 8 percent of India's total population and is the second-largest population of people with diabetes in the world (International Diabetes Federation, 2014). The day-to-day management of type 2 diabetes is difficult anywhere in the world, and, as we have argued elsewhere, may be especially challenging for women in North India because of healthcare access issues, and because of cultural norms circumscribing their behavior (Weaver, 2014, Weaver and Hadley, 2011). In North India, women's adherence to powerful social norms surrounding service to others is a crucial part of female gendered behavior (Derné, 1995, Donner, 2008, Standing, 1991) and shifts the emphasis away from self care (Weaver, 2014, Weaver and Hadley, 2011).

The present study focuses on diabetic North Indian women's mental health because diabetes has been consistently linked with depression in other settings (Anderson et al., 2001, Egede and Ellis, 2010), and because this comorbidity can have serious consequences for diabetic people's health and wellbeing (DeGroot et al., 2001, Katon and Ciechanowski, 2002). Little is known about the epidemiology of common mental disorders in India for reasons including the strong stigma that persists around mental ill health, the relatively recent introduction of biomedical psychiatry, and the challenges of screening India's vast population. A recent population-based study, however, documented levels of depression around 15 percent in urban South India (Poongothai et al., 2009). In our discussions with women about the causes of diabetes, the strikingly common use of the generalized stress term “tension” (Halliburton, 2005, Pereira et al., 2007) led us to suspect that stress might have important connections to women's experiences of diabetes (Weaver, 2014, Weaver and Kasier, 2014, Weaver and Hadley, 2011). This study accordingly assessed mental health using standard screening tools as well as a locally-derived instrument to assess “tension” among diabetic and non-diabetic women.

The biocultural theoretical framework employed in this study asserts that culture shapes political economy, influencing the range of choices available to individuals for managing their health (Goodman and Leatherman, 1998), and that culture and biology exist in a dialectical relationship (Hruschka et al., 2005). The power of structural-cultural factors as both mediators and moderators of disease risk (Singer, 2009) may be particularly pronounced in the case of diet- and lifestyle-related illnesses like type 2 diabetes, because their courses and outcomes are highly dependent on personal choices, which are in turn shaped by cultural and political-economic forces (Brown and Krick, 2001, Worthman and Kohrt, 2005). Medical anthropologists long have emphasized the importance of explanatory models, or our narratives about the causes and consequences of our own illnesses, for actual health outcomes (Kleinman, 1988). Along with these narratives, biomarkers that index hard-to-quantify facets of life, such as chronic stress, have proven useful for biocultural anthropologists interested in integrating qualitative data with physiological processes (Worthman and Costello, 2009), and are used in this study. For instance, the acute phase protein CRP is a marker of the chronic low-grade systemic inflammatory processes implicated in pathogenesis of several chronic conditions, including heart disease and diabetes (King et al., 2003, Ridker et al., 2003). These relationships have been documented among South Asian populations (Chambers et al., 2001, Forouhi et al., 2001). CRP has been directly linked to BMI (Yudkin et al., 1999) and also to insulin resistance independent of obesity in Western groups (Esposito et al., 2003, McLaughlin et al., 2002) and North Indian (Mahajan et al., 2009). Additionally, circulating levels of antibodies to Epstein–Barr virus (EBV) consistently have been linked to daily stress levels in individuals infected with the virus (Glaser and Kiecolt-Glaser, 2005), which constitutes 80–90% of adults in Western settings by the age of 40 (Jones and Straus, 1987). EBV has been linked to a wide array of social and psychogenic stressors such as relationship problems, social isolation, and depression (Cacioppo et al., 2002, Esterling et al., 1993, Kiecolt-Glaser, 1999).

The analyses presented here are designed to address two hypotheses: First, we expect that diabetic women will experience higher levels of psychological distress (depression, anxiety, and “tension”) than non-diabetic women (H1). We further anticipate that diabetic women with suboptimal diabetes control will report greater distress than diabetic women with optimal diabetes control (H1a), and that the relationship between diabetes control and distress will be moderated by the degree to which diabetic women experience disability in key daily tasks (H1b). Second, we anticipate that biomarkers of generalized inflammation and immune stress will be related to women's diabetes and/or mental health (H2). Specifically, C-reactive protein (indexing inflammation) will be associated with body mass index and age (H2a), blood sugar control (H2b), and mental health (depression, anxiety, and “tension”) (H2c). Epstein–Barr virus antibodies (indexing immune stress) will be associated with variables that indicate stress, which in this study include socioeconomic status (low socioeconomic status being a potent stressor; Dressler and Bindon, 2000), depression, anxiety, “tension” scores, stressful life events, and the measure of disability related to diabetes (H2d).