Document Type : Original Article


1 MA, Department of Family Counseling, North Tehran Branch, Islamic Azad University, Tehran, Iran.

2 Assistant Professor, Department of Psychology, North Tehran Branch, Islamic Azad University, Tehran, Iran.



Given the importance of mental health in self-care of patients with type 2 diabetes and the relationship between cognitive flexibility and emotion regulation with mindfulness, the present study aimed to investigate the mediating role of cognitive flexibility in the relationship between cognitive emotion regulation strategies and mindfulness in patients with type 2 diabetes. The present study was conducted using correlation method and structural equation modeling. The statistical population of the study consisted of all men and women with type 2 diabetes referred to Imam Khomeini Hospital in Tehran. 253 participants were selected using convenience sampling. Participants completed the Garnefski & Kraaij (2006) Cognitive Emotion Regulation Questionnaire, the Kentucky Inventory of Mindfulness Skills (Baer, Smith & Allen, 2004), and the Cognitive Flexibility Inventory (Dennis & Vander Wal, 2010). The results showed a positive overall path coefficient between adaptive cognitive emotion regulation strategies and mindfulness (P = 0.005, β = 0.243) and a negative overall path coefficient between maladaptive cognitive emotion regulation strategies and mindfulness (P = 0.001, β = -0.453). The path coefficient between cognitive flexibility and mindfulness was positive and significant (P = 0.009, β = 0.273). The indirect path coefficient between adaptive cognitive emotion regulation strategies and mindfulness was positive (P = 0.007, β = 0.094) and the indirect path coefficient between maladaptive cognitive emotion regulation strategies and mindfulness was negative and significant (P = 0.009, β = -0.117). With an increase in emotion regulation skills, cognitive flexibility and mindfulness also increase in patients with type 2 diabetes.


Ajele, W. K., Oladejo, T. A., Akanni, A. A., & Babalola, O. B. (2021). Spiritual intelligence, mindfulness, emotional dysregulation, depression relationship with mental well-being among persons with diabetes during COVID-19 pandemic. Journal of Diabetes & Metabolic Disorders, 20(2), 1705-1714.
Arici-Ozcan, N., Cekici, F., & Arslan, R. (2019). The relationship between resilience and distress tolerance in college students: The mediator role of cognitive flexibility and difficulties in emotion regulation. International Journal of Educational Methodology, 5(4), 525-533.  Doi: 10.12973/ijem.5.4.525
Baer, R. A., Smith, G. T., & Allen, K. B. (2004). Assessment of mindfulness by self-reports the Kentucky inventory of mindfulness skills. Assessment, 11(3), 191-206.
Braem, S., & Egner, T. (2018). Getting a grip on cognitive flexibility. Current Directions in Psychological Science, 27(6), 470-476. DOI: 10.1177/0963721418787475 
Canas, J. J., Fajardo, I., & Salmeron, L. (2006). Cognitive flexibility. International encyclopedia of ergonomics and human factors, 1(3), 297-301.
Coccaro, E. F., Lazarus, S., Joseph, J., Wyne, K., Drossos, T., Phillipson, L., & de Groot, M. (2021). Emotional regulation and diabetes distress in adults with type 1 and type 2 diabetes. Diabetes Care, 44(1), 20-25.
Dennis, J. P., & Vander Wal, J. S. (2010). The cognitive flexibility inventory: Instrument development and estimates of reliability and validit, Cogn Ther Res, 34, 241-253.
DiNardo, M. M., Greco, C., Phares, A. D., Beyer, N. M., Youk, A. O., Obrosky, D. S., ... & Siminerio, L. (2022). Effects of an integrated mindfulness intervention for veterans with diabetes distress: a randomized controlled trial. BMJ Open Diabetes Research and Care, 10(2), e002631. doi: 10.1136/bmjdrc-2021-002631 
Ebrahimi, S., Jafari, F., & Ranjbar Soodjani, Y. (2018). The relationship between mindfulness and emotion regulation strategies in students. Rooyesh-e-Ravanshenasi, 7(5), 30-13.  (In Persian) 
Garland, E. L., Gaylord, S. A., & Fredrickson, B. L. (2011). Positive reappraisal mediates the stress-reductive effects of mindfulness: An upward spiral process. Mindfulness, 2(1), 59-67.
Garnefski, N., & Kraaij, V. (2006). Relationships between Cognitive Emotional Regulation Strategies and Depressive Symptoms: a Comparative Study of Five Specific Samples. Personality and Individual Differences, 40, 1659-1669.
Garofalo, C., Gillespie, S. M., & Velotti, P. (2020). Emotion regulation mediates relationships between mindfulness facets and aggression dimensions. Aggressive behavior, 46(1), 60-71.
Guendelman, S., Medeiros, S., & Rampes, H. (2017). Mindfulness and emotion regulation: Insights from neurobiological, psychological, and clinical studies. Frontiers in psychology, 220.
Guo, J., Wang, H., Ge, L., Valimaki, M., Wiley, J., & Whittemore, R. (2022). Effectiveness of a nurse‐led mindfulness stress‐reduction intervention on diabetes distress, diabetes self‐management, and HbA1c levels among people with type 2 diabetes: A pilot randomized controlled trial. Research in Nursing & Health, 45(1), 46-58.
Hambour, V. K., Zimmer-Gembeck, M. J., Clear, S., Rowe, S., & Avdagic, E. (2018). Emotion regulation and mindfulness in adolescents: Conceptual and empirical connection and associations with social anxiety symptoms. Personality and Individual Differences, 134, 7-12.
Kaunhoven, R. J., & Dorjee, D. (2021). Mindfulness Versus Cognitive Reappraisal: the Impact of Mindfulness-Based Stress Reduction (MBSR) on the Early and Late Brain Potential Markers of Emotion Regulation. Mindfulness, 12(9), 2266-2280.
Khodapanah, M., Sohrabi, F., Ahadi, H., & Taghiloo, S. (2018). Structural model of brain-behavioral system, impulsivity, emotional dysregulation, and cognitive emotion regulation with eating behavior. Journal of Education and Health Promotion, 6(3), 251-265.  (In Persian) 
Kline, R. B. (2016). Principles and practice of structural equation modeling, edition 4, Guilford press, New York & London.
Koerner, R., & Rechenberg, K. (2022). Mindfulness in adolescents and young adults with diabetes: An integrative review. Complementary Therapies in Clinical Practice, 101659.
Malinowski, P. (2013). Neural mechanisms of attentional control in mindfulness meditation. Frontiers in neuroscience, 7, 8-28.
Meyers, L. S, Gamest. G., & Goarin, A. J. (2006).Applied multivariate research, design and interpretation, thousand oaks. London. New Deihi, Sage publication.
Mousavi, A. S., Parsa Garabaghi, Z., Siavash, B., & Sharifi Zavashti, M. (2022). The effectiveness of mindfulness therapy on emotion regulation difficulties and cognitive fusion in patients with type 2 diabetes. Journal of Disability Studies, 12, 152-152.  (In Persian) 
Muthiah, M., Ng, C. H., Chan, K. E., Fu, C. E., Lim, W. H., Tan, D. J. H., ... & Noureddin, M. (2023). Type 2 diabetes mellitus in metabolic-associated fatty liver disease vs. type 2 diabetes mellitus Non-alcoholic fatty liver disease: a longitudinal cohort analysis. Annals of Hepatology, 28(1), 100762.
Ochsner, K. N., & Gross, J. J. (2008). Cognitive emotion regulation: Insights from social cognitive and affective neuroscience. Current directions in psychological science, 17(2), 153-158.
Paschke, L. M., Dörfel, D., Steimke, R., Trempler, I., Magrabi, A., Ludwig, V. U., ... & Walter, H. (2016). Individual differences in self-reported self-control predict successful emotion regulation. Social cognitive and affective neuroscience, 11(8), 1193-1204.
Payande, F., Borjalil, M., & Kolehreniagolkar, M. (2020). Comparison of emotion regulation and frustration tolerance in women with and without type 2 diabetes. Journal of Disability Studies, 10, 69-69.  (In Persian) 
Pineda-Alhucema, W., Aristizabal, E., Escudero-Cabarcas, J., Acosta-Lopez, J. E., & Vélez, J. I. (2018). Executive function and theory of mind in children with ADHD: A systematic review. Neuropsychology Review, 28(3), 341-358.
Roemer, L., Williston, S. K., & Rollins, L. G. (2015). Mindfulness and emotion regulation. Current Opinion in Psychology, 3, 52-57.
Saito, J., & Kumano, H. (2022). The patterns of acceptance, mindfulness, and values for Japanese patients with type 2 diabetes mellitus: a web-based survey. BioPsychoSocial Medicine, 16(1), 1-9.
Samani, S., & Sadeghi, L. (2010). Adequacy of psychometric indices of cognitive emotion regulation questionnaire. Methods and Psychological Models, 1, 51-62.  (In Persian) 
Shahbaz, W., & Parker, J. (2022). Workplace mindfulness: An integrative review of antecedents, mediators, and moderators. Human Resource Management Review, 32(3), 100849.
Soltani, I., Shareh, H., Bahreynian, S. A., & Formani, A. (2013). The mediating role of cognitive flexibility in the relationship between coping styles and resilience to depression. Pazhohande, 18(2), 88-96.  (In Persian) 
Sun, H., Saeedi, P., Karuranga, S., Pinkepank, M., Ogurtsova, K., Duncan, B. B., ... & Magliano, D. J. (2022). IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes research and clinical practice, 183, 109119.
Sünbül, Z. A. (2020). Mindfulness, positive affection and cognitive flexibility as antecedents of trait resilience. Studia Psychologica, 62(4), 277-290.
Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. Monographs of the society for research in child development, 25-52.
Vatan Khah Amjad, F., Shams, S., Reshtiani, F., & Mohammadi, S. (2021). The relationship between brain-behavioral systems and emotion regulation difficulties with depression symptoms in individuals with type 2 diabetes: The mediating role of cognitive flexibility. Rooyesh-e-Ravanshenasi, 10(11), 256-241. (In Persian) 
Verhulst, C. E., Fabricius, T. W., Nefs, G., Kessels, R. P., Pouwer, F., Teerenstra, S., ... & de Galan, B. E. (2022). Consistent effects of hypoglycemia on cognitive function in people with or without diabetes. Diabetes Care, 45(9), 2103-2110.
Webb, T. L., Miles, E., & Sheeran, P. (2012). Dealing with feeling: a meta-analysis of the effectiveness of strategies derived from the process model of emotion regulation. Psychological bulletin, 138(4), 775–808.
Whitfield, T., Barnhofer, T., Acabchuk, R., Cohen, A., Lee, M., Schlosser, M., ... & Marchant, N. L. (2022). The effect of mindfulness-based programs on cognitive function in adults: a systematic review and meta-analysis. Neuropsychology Review, 32(3), 677-702.
Zou, Y., Li, P., Hofmann, S. G., & Liu, X. (2020). The mediating role of non-reactivity to mindfulness training and cognitive flexibility: A randomized controlled trial. Frontiers in psychology, 11, 1053.