Can You Reduce Diabetes Symptomatology by Becoming Your 'Best Possible Self': The Role of Stress and Resilience
Phase: NA
Conditions: Diabetes Mellitus, Type 2
Sponsor: Liverpool John Moores University

 
 
 
 
 
 
 
 
 
 
 
Can You Reduce Diabetes Symptomatology by Becoming Your 'Best Possible Self'?: The Role of Stress and 
Resilience 
 
Study Protocol and Statistical Analysis Plan 
 
Last Edited: 14/09/2018 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Protocol 
 
Title: Can You Reduce Diabetes Symptomatology by Becoming Your ‘Best Possible Self’?: The Role of Stress 
and Resilience. 
 
Research Question  
 
How does the ‘Best Possible Self’ Task influence stress and resilience when used as a diabetes prevention 
tool? 
 
Background 
 
Diabetes mellitus continues to be a global burden and it affects millions of people around the world 
(Bommer et al., 2017). Prevalence figures from 2015 revealed that approximately 5 million adults in England 
alone were at high risk of developing type 2 diabetes specifically (Public Health England, 2016), a form of the 
disease that is largely preventable via lifestyle changes (Klein, Sheard, Pi-Sunyer, Daly, Wylie-Rosett, 
Kulkarni, & Clark, 2004). Typically, education interventions are utilised in efforts to promote awareness and 
generate behavioural change prior to formal diagnosis (Lian, McGhee, Chau, Wong, Lam, & Wong, 2017; 
Roberts, Barry, Craig, Airoldi, Bevan, & Greenhalgh, 2017) but this is not always enough to motivate 
individuals to act (Horigan, Davies, Findlay-White, Chaney, & Voates, 2017). Research has demonstrated that 
emotionality plays a significant role not only in lifestyle change but also in symptom management 
(Rasmussen, Smith, Maxson, Bernard, Cha, Agerter, & Shah, 2013). Experiencing mental illness, distress, or 
even just a high frequency of negative emotions can negatively influence dieting and exercising behaviours 
(Ciechanowski, Katon, & Russo, 2000), for example, increasing risk. However, novel findings have shown that 
experiencing positive emotions (such as happiness, optimism, interest, feelings of strength, etc.) can have 
the opposite effect and may help empower the individual to make the changes they need to improve their 
health (Garland, Fredrickson, Kring, Johnson, Meyer, & Penn, 2010). Interventions designed to foster positive 
emotions specifically are in development across psychology and have shown to improve mental as well as 
physical health outcomes (Chew, Vos, Heijmanns, Metzendorf, Scholten, & Rutten, 2015). This has been 
supported by our own investigations whereby we discovered that one such “positive” intervention reduces 
certain diabetes symptoms regardless of the individual’s level of risk. 
The positive intervention we have been using is an adapted version of the ‘Best Possible Self’ (BPS) task – a 
goal setting exercise that has shown to be effective in improving illness management and facilitating positive 
emotions (King, 2001). Its influence on diabetes symptoms is a novel finding, and with this study we are hoping 
to further investigate how it achieves this effect. According to the Stress Buffering Model of Physical Activity 
(Pressman & Cohen, 2005), psychological stress is the catalyst that triggers behavioural and physiological 
responses critical to health and positive emotions improve health by helping people to cope. The Broaden and 
Build Theory of Positive Emotions, meanwhile, suggests that this is because positive emotions allow people to 
build resilience (Fredrickson, 2001). Research around stress and resilience has shown these factors to be 
important not only in physical health of people with diabetes (Yi, Vitaliano, Smith, Yi, & Weinger, 2008) but 
for also decreasing illness symptomatology in non-clinical samples more generally (Steinhardt & Dolbier, 
2008). As such, this proposed study aims to assess the role that stress and resilience may play in mediating 
the relationship between BPS and diabetes symptomatology.  
 
Hypotheses: 
 
The ‘Best Possible Self’ task will increase resilience and alleviate stress in order to reduce symptoms of 
diabetes in a non-clinical sample.  
 
 
 

Methodology 
 
See flowchart below: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Participants Recruited 
Interested individuals will be provided with an information sheet, the opportunity to 
ask questions, and a link to the study where they can provide consent. 
Participants Randomised 
150+ participants are then randomised into one of two conditions on 
Qualtrics. 
Intervention Group 
Participants receive the BPS 
straight away. 
Control 
Participants are told they are on a 
waiting list to receive the BPS at 
the end of the study period. 
Time Point 1 Questionnaires 
All participants then complete CANRISK (diabetes risk), PSS (stress), 6BRS (resilience), and DSC-R 
(diabetes symptoms) questionnaires. 
4-week interval 
Time Point 2 Questionnaires 
Participants return to Qualtrics and repeat PSS, 6BRS, and DSC-R. 
Debrief 
Study Created 
Following ethical approval, study is created and set up on Qualtrics, an online survey 
system. 
Study Advertised 
Bulk Emails, Social Media, SONA, Public Forums. 

Analysis 
 
A series of MANOVAs will be used to assess the influence of the BPS on diabetes symptoms over time and 
across groups. MANCOVAs will be used to control for diabetes risk. A mediation analysis will be conducted 
using the PROCESS software (Hayes, 2012) to assess whether the relationship between the BPS and diabetes 
symptoms is mediated by stress and resilience. 
 
 
 
 
 
 
 
 
 
 
 
References 
 
Bommer, C. Heesemann, E., Sagalova, V., Manne-Goehler, J., Atun, R., Barnighausen, T., & Vollmer, S. (2017). 
The global economic burden of diabetes in adults aged 20-79 years: A cost-of-illness study. The Lancet 
Diabetes & Endocrinology, 5(6), 423-430. 
 
Chew, B. H., Vos, R., Heijmans, M., Metzendorf, M. I., Scholten, R. J., & Rutten, G. E. (2015). Psychological 
interventions for diabetes-related distress in adults with type 2 diabetes mellitus. The Cochrane Library. 
 
Ciechanowski, P. S., Katon, W. J., & Russo, J. E. (2000). Depression and diabetes: Impact of depressive 
symptoms on adherence, function, and costs. Archives of Internal Medicine, 160(21), 3278-3285. 
 
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory 
of positive emotions. American Psychologist, 56(3), 218. 
 
Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. L. (2010). Upward spirals 
of positive emotions counter downward spirals of negativity: Insights from the broaden-and-build theory and 
affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clinical 
Psychology Review, 30(7), 849-864. 
 
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, 
and conditional process modelling. 
 
Horigan, G., Davies, M., Findlay-White, F., Chaney, D., & Coates, V. (2017). Reasons why patients referred to 
diabetes education programmes choose note to attend: A systematic review. Diabetes Medicine, 34(1), 14-
26. 
 
King, L. A. (2001). The health benefits of writing about life goals. Personality and Social Psychology Bulletin, 
27(7), 798-807. 
 
Klein, S., Sheard, N., F., Pi-Sunyer, X., Daly, A., Wylie-Rosett, J., Kulkarni, K., & Clark, N. G. (2004). Weight 
management through lifestyle modification for the prevention and management of type 2 diabetes: 
Rationale and strategies. Diabetes Care, 27(8), 2067-2073. 
 
Stress/Resilience 
BPS 
Symptomatology 

Lian, J. X., McGhee, S. M., Chau, J., Wong, C. K. H., Lam, C. L. K., & Wong, W. C. W. (2017). Systematic review 
on the cost-effectiveness of self-management education programme for type 2 diabetes mellitus. Diabetes 
Research and Clinical Practice, 127, 21-34. 
 
Pressman, S. D., & Cohen, S. (2005). Does positive affect influence health? Psychological Bulletin, 131(6), 
925. 
 
Public Health England (2015). Analysis of non-diabetes hyperglycaemia prevalence in England (Press 
Release). Retrieved from https://www.gov.uk/government/publications/nhs-diabetes-prevention-
programme-non-diabetic-hyperglycaemia. 
 
Rasmussen, N. H., Smith, S. A., Maxson, J. A., Bernard, M. E., Cha, S. S., Agerter, D. C., & Shah, N. D. (2013). 
Association of HbA1c with emotion regulation, intolerance of uncertainty, and purpose in life in type 2 
diabetes mellitus. Primary Care Diabetes, 7(3), 213-221. 
 
Roberts, S., Barry, E., Craig, D., Airoldi, M., Bevan, G., & Greenhalgh, T. (2017). Preventing type 2 diabetes: 
Systematic review of studies of cost-effectiveness of lifestyle programmes and metformin, with and without 
screening, for pre-diabetes. BMJ Open, 7(11), e017184. 
 
Steinhardt, M., & Dolbier, C. (2008). Evaluation of a resilience intervention to enhance coping strategies and 
protective factors and decrease symptomatology. Journal of American College Health, 56(4), 445-453. 
 
Yi, J. P., Vitaliano, P. P., Smith, R. E., Yi, J. C., & Weinger, K. (2008). The role of resilience on psychological 
adjustment and physical health in patients with diabetes. British Journal of Health Psychology, 13(2), 311-
325.