Diabetes Stress Management

Patients with type 2 diabetes who incorporate stress management techniques into their routine care can significantly reduce their average blood glucose levels, according to a new study by researchers at Duke University Medical Center.

This is the first large study to show that a simple, cost-effective treatment can have a meaningful therapeutic effect on the control of blood sugar, according to researchers. Such stress management techniques include instructions on how to identify everyday life stressors and how to respond to them with techniques such as progressive muscle relaxation and breathing exercises.

Stress can increase glucose levels in people with diabetes, making them more susceptible to long-term physical complications such as eye, kidney or nerve disorders. Results of the study are published in the January 2002 issue of the journal Diabetes Care.

"The stress management techniques, when added to standard care, helped reduce glucose levels," said Richard Surwit, Ph.D., lead author of the study and a medical psychologist at Duke. "The change is nearly as large as you would expect to see from some diabetes-control drugs."

Patients in the stress management group showed, on average, a 0.5 percent reduction on the hemoglobin A1c (HbA1c) test-a standard laboratory test used to determine average blood glucose levels in people with diabetes. However, 32 percent of the patients in that group showed an even greater improvement by lowering their glucose level by 1 percent or more.

According to Surwit, that amount of glucose level reduction is what the Food and Drug Administration (FDA) considers sufficient when reviewing drugs seeking approval for diabetes control.

A total of 108 patients with type 2 diabetes-also known as adult-onset diabetes-participated in five 30-minute educational sessions about diabetes. The basic program focused on general facts (such as signs or symptoms of the disease), complications (such as foot, eye and dental issues), healthy eating and treatment information. There were no discussions of specific recommendations or glycemic goals.

The patients were randomly enrolled in the educational sessions either with or without stress management training. Stress-management techniques were taught by nurses or graduate students specifically trained for the study. The training included progressive muscle relaxation, mental imagery, breathing techniques and instructions on how to modify one's physiologic, cognitive and behavioral responses to stress.

At the beginning of the study, and at subsequent times throughout the year-long tracking period, patients were tested using the HbA1c test to evaluate their blood sugar control and with various questionnaires to assess their trait anxiety. Such trait anxiety included perceived levels of stress, anxiety and psychological health. All participants were at least 30 years old and currently managing their diabetes with diet, exercise and non-insulin medications.

"Patients with type 2 diabetes might be at increased health risk from the effects of stress," Surwit said. "Experiencing stress is associated with the release of hormones that lead to energy mobilization-known as the 'fight or flight' response. Key to this energy mobilization is the transport of glucose into the bloodstream, resulting in elevated glucose levels, which is a health threat for people with diabetes."

Stress also can disrupt diabetes control indirectly through its effects on diet and exercise, he said.

After six months, the control group began to show deterioration in their glucose levels, while the stress management group continued to improve. By the end of one year, 32 percent of the patients randomized to stress management had HbA1c levels that were lower by 1 percent or more. In contrast, only 12 percent of the control subjects had levels that were this much lower.

According to Surwit, the effect cannot be explained by changes in body mass index, diet or exercise because the two groups did not differ on these variables during the year they were followed.

The HbA1c test has been shown to be effective in predicting coronary disease and other risks to people with diabetes, including the development of microvascular complications in the kidneys or eyes, according to Surwit.

"Managing stress can significantly improve a patient's control of their diabetes," Surwit said. "These techniques are simple, quick to learn, and have been shown to work for multiple conditions, including coronary syndromes. There are many self-help books and other commercially available materials about stress management from which patients can learn these techniques."

According to Surwit, future studies may look at whether or not a strictly self-help approach to stress management can be equally as effective as the group-based educational intervention tested in this study.

The study was supported by grants from the National Institute of Diabetes and Digestive & Kidney Diseases and the National Institutes of Health.

Other authors on the study include: Mark Feinglos, M.D., Miranda Van Tilburg, Nancy Zucker, Cynthia C. McCaskill, Priti Parekh, Christopher L. Edwards, Ph.D., Paula Williams and James D. Lane, Ph.D., all of Duke University Medical Center.

How Stress Affects Diabetes

In people who have diabetes, stress can alter blood sugar levels. It does this in two ways. First, people under stress may not take good care of themselves. They may drink more alcohol or exercise less. They may forget, or not have time, to check their sugar levels or plan good meals. Second, stress hormones may also alter blood sugar levels directly.

Scientists have studied the effects of stress on glucose levels in animals and people. Diabetic mice under physical or mental stress have elevated glucose levels. The effects in people with type 1 diabetes are more mixed. While most glucose levels go up with mental stress, others can go down. In people with type 2 diabetes, mental stress often raises blood sugar levels.

Physical stress, such as illness or injury, causes higher blood sugar levels in people with either type of diabetes. For some people with diabetes, controlling stress with relaxation therapy seems to help. It is more likely to help people with type 2 diabetes than people with type 1 diabetes. This difference makes sense. Stress blocks the body from releasing insulin in people with type 2 diabetes, so cutting stress may be more helpful for these people. People with type 1 diabetes don't make insulin, so stress reduction doesn't have this effect. But reducing stress can help people with type 1 diabetes take better care of themselves.

It's easy to find out whether mental stress affects your glucose control. Before checking your glucose levels, write down a number rating your mental stress level on a scale of one to 10. Then write down your glucose level next to it. After a week or two, look for a pattern. Drawing a graph may help you see trends better. Do high stress levels often occur with high glucose levels, and low stress levels with low glucose levels? If so, stress may affect your glucose control.

Stress and Personality

You have some control over your reaction to stress. You can learn to relax and reverse the body's hormonal response to stress. And, of course, you may be able to change your life to relieve sources of stress.

Coping style-how a person deals with stress-affects people's stress levels. For example, some people have a problem-solving attitude. They say to themselves, "What can I do about this problem?" They try to change their situation to get rid of the stress.

Other people talk themselves into accepting the problem as OK. They say to themselves, "This problem really isn't so bad after all." These two methods of coping are usually helpful. People who use them tend to have less blood sugar elevation in response to mental stress.

Learning to Relax

There are many ways to help yourself relax:

Breathing exercises

Sit or lie down and uncross your legs and arms. Take in a deep, deep breath. Then push out as much air as you can. Breathe in and out again, this time relaxing your muscles on purpose while breathing out. Keep breathing and relaxing for 5 to 20 minutes at a time. Do the breathing exercises at least once a day.

Progressive relaxation therapy

In this technique, which you can learn in a clinic or from an audio tape, you tense muscles, then relax them.

Exercise

Another way to relax your body is by moving it through a wide range of motion. Three ways to loosen up through movement are circling, stretching, and shaking parts of your body. To make this exercise more fun, move with music.

Replace bad thoughts with good ones.

Each time you notice a bad thought, purposefully think of something that makes you happy or proud. Or memorize a poem, prayer, or quote and use it to replace a bad thought.

Whatever method you choose to relax, practice it. Just as it takes weeks or months of practice to learn a new sport, it takes practice to learn relaxation.

Other Ways to Reduce Mental Stress

You may be able to get rid of some stresses of life. If traffic upsets you, for example, maybe you can find a new route to work or leave home early enough to miss the traffic jams. If your job drives you crazy, put in for a transfer if you can, or discuss with your boss how to improve things if possible. As a last resort, you can look for another job. If you are at odds with a friend or relative, you can make the first move to patch things up.

Some sources of stress are never going to go away, no matter what you do. Having diabetes is one of those. Still, there are ways to reduce the stresses of living with diabetes. Support groups can help. Knowing other people in the same situation helps you feel less alone. Making friends in a support group can lighten the burden of diabetes-related stresses.

There are other ways to fight stress as well. Sometimes adding positive things to your life can help. You can start an exercise program or join a sports team. You can take dance lessons or join a dancing club. You can start a new hobby or learn a new craft. You can volunteer to help at a hospital or charity.

Dealing directly with diabetes-related stress also can help. Think about the aspects of your life with diabetes that are the most stressful for you. It might be taking your medication, checking your blood glucose levels regularly, exercising or eating as you should. You can get help with any of these issues. Ask a member of your diabetes team for a referral. Sometimes stress can be so severe that you feel overwhelmed. Then counseling or psychotherapy might help. Talking with a therapist may help you come to grips with your problems. You may learn new ways of coping or new ways of changing your behavior.

This article originally appeared in the January 2002 issue of HME Business.

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