This study is of a cross-sectional nature, and it recruited individuals diagnosed with T2DM who sought medical care within the endocrine inpatient department and outpatient clinic of a tertiary healthcare facility situated in Chengdu during the period spanning from October 2022 to June 2023.Inclusion criteria: ① Patients who conformed to the diagnostic standards set forth by the World Health Organization in 1999 for T2DM (34). ② Patients with a confirmed T2DM diagnosis for a duration of no less than 6 months. ③Age range: 18 years to 80 years. ④Cognitively sound, capable of regular communication, and possessing a comprehensive understanding of the questionnaire’s content. ⑤Individuals who have provided informed consent and willingly enrolled in this investigation. Exclusion criteria: ① Patients presenting severe chronic ailments, such as those affecting the cardiovascular, cerebral, hepatic, renal, or pulmonary systems; ② Patients afflicted with psychiatric disorders or cognitive impairments (excluding depressed patients); ③ Patients in critical medical states, precluding their ability to collaborate with the investigative procedures.

Sample size calculation:In accordance with the Kendall sample size estimation method, the sample size was determined to be a minimum of ten times the number of variables (35). This study incorporated four research instruments, which included a 12-item General Information Questionnaire, a 3-item Social Support Rating Scale, and a 5-item Hamilton Depression Scale, a 3-item Toronto Narrative Alexithymia Scale, totaling 23 items. Hence, the total sample size comprised 230 cases. To safeguard against potential sample attrition influencing the study outcomes, a 20% sample loss margin was incorporated, resulting in a final sample size of 276 cases, as dictated by the requirements of structural equation modeling. The final sample size of 318 cases was included in conjunction with the actual clinical survey

Prior to commencing the survey, the researcher (XF) engaged in a comprehensive review of the questionnaire’s content. Additionally, any queries or uncertainties were addressed through consultation with pertinent experts or professionals. Throughout the survey process, the researcher elucidated the study’s protocol to the participating patients. Those who consented to participate formally by signing the written informed consent document were subsequently entrusted to independently complete the questionnaires following standardized instructions provided by the researcher. In instances where participants encountered difficulties during the questionnaire completion, the researcher offered appropriate assistance. Upon the conclusion of the questionnaire administration, the researcher collected the completed forms on-site to ensure their comprehensive fulfillment and promptly addressed any vacancies requiring supplementation.

The study was approved by the Ethics Committee of the First Affiliated Hospital of Chengdu Medical College (2022CYFYIRB-BA-Oct19), and the subjects signed an informed consent form before the investigation.

The data were exported from the EpiData management software (Chinese version) and subjected to analysis using IBM SPSS 26.0 software. Quantitative data were presented as mean ± standard deviation (`x ± s), while qualitative data were expressed in terms of case count and percentage (%). Linear regression was employed to scrutinize the impact of social support, depression, and alexithymia on glycemic control, and Pearson’s correlation was utilized to investigate the interrelations among these variables. The construction of a structural equation model for factors impacting glycemic control in patients with type 2 diabetes mellitus was executed using AMOS 26.0 software. This encompassed an evaluation based on several goodness-of-fit indices, namely Goodness of Fit Index (GFI), Incremental Fit Index (IFI), Comparative Fit Index (CFI), Standardized Fit Index (NFl), Relative Fit Index (RFI), Non-normalized Fit Index (TLI), Normed Fit Index (NFl), and Root Mean Square Error of Approximation. The indices IFI, CFI, NFI, RFI, and TLI all exceeded 0.9, with RMSEA below 0.08, and 2/DF below 3, adhering to accepted standards (40). A statistically significant difference was ascribed to instances with a P-value less than 0.05.

A total of 318 study participants were enrolled in this investigation, comprising 152 males (47.8%) and 166 females (52.2%). Their age distribution was as follows: 22 individuals (6.9%) aged 18-44, 174 individuals (54.7%) aged 45-64, and 122 individuals (38.4%) aged 65 and above. In terms of marital status, 267 participants (84.0%) were married, while 51 participants (16.0%) were not. Employment status revealed 98 participants (30.8%) were employed, and 220 participants (69.2%) were not actively working. Health insurance coverage was prevalent, with 295 participants (92.8%) having it, while 23 participants (7.2%) did not possess health insurance. Additional demographic details of the study cohort are delineated in Table 1 .

The glycemic control level among T2DM patients was determined to be (8.85 ± 2.107), while the indices for alexithymia, social support, and depression were measured at (58.05 ± 4.382), (34.29 ± 4.420), and (7.17 ± 3.367), respectively. Notably, suboptimal glycemic control was evident in 75.47% of cases, with 31.13% of participants exhibiting alexithymia, and a significant 94.97% experiencing an intermediate level of social support. Furthermore, depressive symptoms were reported by 45.6% of the participants. Detailed findings are presented in Table 2 .

A linear regression analysis concerning alterations in HbA_1c was performed, with HbA_1c serving as the dependent variable and alexithymia, social support, and depression acting as independent variables. The findings underscored that alexithymia, social support, and depression emerged as significant determinants influencing HbA_1c levels in patients diagnosed with T2DM (P<0.05). Elaborative outcomes are delineated in Table 3 .

Pearson correlation analysis was employed to scrutinize the associations among social support, depression, alexithymia, and blood glucose control in individuals diagnosed with T2DM. The outcomes revealed that HbA_1c exhibited a positive correlation with both alexithymia (r=0.392, P<0.01) and depression (r=0.509, P<0.01), while demonstrating a negative correlation with social support (r=-0.338, P<0.01). Furthermore, alexithymia displayed a negative correlation with social support (r=-0.357, P<0.01) and a positive correlation with depression (r=0.345, P<0.01). Notably, social support exhibited no significant association with depression (r=-0.095, P>0.05). Comprehensive details are available in Table 4 .

Derived from the initial model outcomes, inoperative paths were excised, and the initial model underwent refinement through amalgamation with correction indices. This culminated in the formulation of the definitive structural equation model delineating glycemic control in individuals diagnosed with T2DM, as elucidated in Figure 1 . The model, presented in a standardized format, encompasses standardized path coefficients. Subsequently, the revised model was re-fitted to the dataset employing the maximum likelihood method. The ensuing results indicated commendable fit indices, including RMSEA=0.043 (<0.08), χ2/df=2.577 (<3), GFI=0.973 (>0.9), AGFI=0.948 (>0.9), IFI=0.952 (>0.9), TLI=0.918 (>0.9), and CFI=0.949 (>0.9), all well within the normative range of values. Additionally, NFI=0.878 (<0.9) and RFI=0.804 (<0.9), though marginally below 0.9, still fall within the acceptable threshold, affirming the enhanced fit of the refined model. For comprehensive specifics, refer to Table 5 .

The refined model exhibited fitting indices within acceptable parameters. The model outcomes indicated that social support manifested a negative association with depression (β=-0.336, t=-2.398, P=0.016), and likewise, social support displayed a negative correlation with alexithymia (β=-0.405, t=-3.566, P<0.001). Moreover, social support revealed an inverse relationship with glycemic control (β=-0.346, t=-3.437, P<0.001). Conversely, depression exhibited a positive connection with alexithymia (β=0.318, t=3.233, P=0.001) and also demonstrated a positive correlation with glycemic control (β=0.434, t=4.168, P<0.001). Notably, alexithymia exhibited no statistically significant relationship with glycemic control (P>0.05), as elucidated in Table 6 .

The study results revealed that the comprehensive social support score for patients diagnosed with T2DM was (34.29 ± 4.42), indicating a moderate level. This finding aligns with the research conducted by Al-Dwaikat et al. (41) and contrasts with the outcomes reported by Qin Wen et al. (42) (39.27 ± 8.82), where social support levels were higher. Specifically, the subjective support score ranked highest, followed by the objective support score, while the social support utilization score was the lowest. This pattern resonates with the outcomes of a social support survey for diabetic patients conducted by Liu Qing et al. (43). Notably, patients exhibited a relatively high subjective perception of acquiring social support; however, the practical benefits derived from this assistance were diminished, impeding their ability to fully harness external aid. This suboptimal utilization of support resulted in consequences such as social isolation and delayed medical intervention (44), thereby influencing the efficacy of disease treatment. Social support not only exerts a direct positive influence on well-being but also functions as a buffer, shielding individuals from health issues induced by excessive stress (22). Adequate social support not only serves as a protective factor for individuals navigating health crises across diverse medical conditions but also correlates with a reduction in medication dependency, expedited recuperation, and enhanced adherence to therapeutic regimens (45). It is imperative to enhance objective support mechanisms and optimize the utilization of social support by patients, thereby maximizing the efficacy of such support systems and mitigating the burden of disease.

The investigation revealed that the glycemic control level among patients with T2DM was (8.85 ± 2.107), surpassing that observed in Polish diabetic cohorts as reported by Cyranka et al. (46) (7.11 ± 1.0) and falling below the corresponding level found in Turkish diabetic subjects in the investigation by Celik et al. (23) (9.98 ± 1.80). This discrepancy underscores the discernible variability in the prevailing state of glycemic control among patients across diverse geographic regions. Notwithstanding the intermediary status of glycemic control observed in the subjects of this investigation, it demonstrated a noteworthy elevation compared to the established normative threshold (7.0%) (6). Nonetheless, the incidence of suboptimal glycemic control persisted at a considerable level. Prolonged exposure to elevated blood glucose levels in patients is known to instigate the onset of macrovascular complications, such as cardiovascular diseases (47), microvascular complications, including retinopathy and nephropathy (48), thereby amplifying the overall risk of mortality (49). Hence, it is recommended that clinical practitioners fortify the regimen of glycemic control in diabetic cohorts to ameliorate adverse pathological outcomes, augment the quality of life for patients, and mitigate the economic burdens associated with the condition.

The current investigation elucidated a positive correlation between alexithymia and glycemic control among patients diagnosed with T2DM, aligning with the findings reported by Celik et al. (23). This concordance implies that individuals exhibiting alexithymic traits tend to manifest inferior glycemic control in comparison to their non-alexithymic counterparts. The failure to recognize body symptoms and emotion perceptions could lead to a further incomprehensible psychological and physical suffering, due to poorly regulated diabetes, which may limit the ability to manage their metabolic disease (50). Within the diabetic population, heightened psychological stress may recurrently or persistently activate glucose metabolic pathways, culminating in aberrant glucose concentrations beyond the normative spectrum. Such perturbations in metabolic homeostasis contribute to an inability to sustain glucose levels within physiological bounds, thereby fostering suboptimal glycemic control. Furthermore, psychological stress exerts a deleterious influence on patient self-management, diminishing adherence to therapeutic regimens and consequently engendering compromised glycemic control (51). Alexithymia emerges as a significant psychological determinant contributing to compromised glycemic control (52). Individuals characterized by alexithymic features tend to defer their pursuit of assistance, owing to challenges in articulating and discerning their personal emotional states. This delay, coupled with a reduction in others’ capacity to perceive the patient’s needs accurately, results in a lapse in the timely fulfillment of the patient’s requisites. This circumstance amplifies the psychological burden borne by the patient and diminishes adherence to the prescribed therapeutic interventions, ultimately culminating in suboptimal glycemic control (23). Nevertheless, in the investigations conducted by Mnif and Hintistan et al (15, 53) concerning alexithymia and glycemic control in T2DM patients, the establishment of a conclusive correlation between glycemic control and alexithymia has not been discerned. This absence of a clear association may be attributed to idiosyncrasies within the sampled populations and variances in the methodologies employed for measurement. Consequently, the inquiry into the interrelation between alexithymia and glycemic control necessitates augmentation through additional related studies to enhance the overall persuasiveness of the research.

The study findings indicate an inverse relationship between glycemic control and social support; specifically, a diminished level of social support correlates with a deterioration in glycemic control among diabetic patients. This concurrence aligns with the outcomes reported by Castillo-Hernandez et al. (54). Psychosocial stressors may also lead to decreased immune surveillance as well as abnormal activation of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal axis (HPA), which may affect the patient’s control of the disease (12). In the context of T2DM, social support encompasses emotional, material, and informational facets, serving as a facilitator for enhancing patient adherence to medication protocols, blood glucose monitoring, and lifestyle modifications (e.g., dietary control, physical exercise) (55). This multifaceted support structure aims to ameliorate patients’ self-management proficiency and, consequently, elevate glycemic control, thereby augmenting the overall efficacy of disease management. Conversely, a paucity of social support may engender a deficiency in requisite medical information and assistance for patients, diminishing their cognizance of the ailment. This may result in a procrastination of disease intervention, thereby impinging upon patients’ self-management capabilities and exerting a deleterious impact on glycemic control.

Furthermore, social support may exert a detrimental impact on glycemic control through its association with depression, a phenomenon akin to the observations made by Burns et al. (56) in diabetic patient cohorts. Beyond the direct provision of tangible and spiritual support, the influence of social support on patients’ psychological state emerges as an additional mechanism by which it can affect glycemic control. Social support serves to mitigate psychological stress, assuage adverse emotional states, empower individuals to confront challenges, and enhance self-efficacy in surmounting obstacles (57). Conversely, inadequate social support may precipitate feelings of isolation, helplessness, and anxiety in recipients, potentially culminating in depressive states. Patients enduring chronic depression may experience a decline in confidence regarding their therapeutic regimen, fostering a lack of motivation for self-management and control. This, in turn, can contribute to suboptimal glycemic control.

The findings further revealed a positive association between depression and blood glucose control, indicating that elevated depression scores correlate with a deterioration in blood glucose regulation, consistent with the observations of Gonzalez et al. (58). Depression may precipitate physiological alterations in patients, contributing to suboptimal glycemic control in diabetic individuals. Mechanistically, this influence is manifested through the activation of the hypothalamo-pituitary-adrenal axis, stimulation of the sympathetic nervous system, and an escalation in inflammatory responses and platelet aggregation (59). Furthermore, depression may exacerbate the clinical condition and heighten the susceptibility to complications. Secondly, depression can instigate alterations in patients’ attitudes and behaviors towards the ailment, diminishing their inclination to actively engage in treatment and detrimentally impacting self-management facets such as dietary practices, exercise, glucose monitoring, and medication adherence (60, 61). This, in turn, exerts an adverse influence on glycemic control, potentially escalating the severity of the disease, amplifying medical expenditures, and heightening the likelihood of diabetic complications and mortality (62). Moreover, depression may disrupt patients’ social functioning, with chronically depressed individuals experiencing a reduction in social engagement and a decline in overall quality of life. These factors may further compromise the proficiency of glycemic control.

This study constitutes a single-center cross-sectional investigation, potentially compromising the representativeness of the encompassed population. Furthermore, the limited sample size may pose a constraint on the generalizability of the findings. To enhance the robustness of future inquiries, multicenter studies incorporating a more diverse diabetic population could be considered, thereby bolstering the external validity of the results. Additionally, intervention studies investigating the impact of alexithymia on glycemic control could be undertaken to augment the persuasiveness of the outcomes.

In this investigation, we formulated a structural equation model encompassing social support, depression, alexithymia, and glycemic control. We scrutinized the intricate pathways through which these factors exert influence on glycemic regulation in diabetic patients. Our findings suggest that enhancing the level of social support and conducting timely assessments of mental health are imperative measures. These interventions aim to ameliorate the physical and psychological stress experienced by patients, subsequently elevating patients’ adherence to treatment and self-management practices. This, in turn, contributes to an enhancement in glycemic control among individuals afflicted with T2DM and those at risk. The optimization of glucose control not only serves to retard the progression of complications and mitigate the risk of mortality but also endeavors to enhance the overall quality of life for patients. Simultaneously, such interventions aspire to alleviate both social and economic burdens associated with T2DM.