Tis the Season: Diabetes and Stress

Stuffed turkeys, sugar plums, and other holiday temptations can really throw a wrench into diabetes management. And even though holiday merrymaking can brighten a winter’s eve, social and family commitments can also add to stress levels.

While the “happiest time of the year” represents a finite period of time, stress-either short-term or chronic-is intimately connected to diabetes. What does current research say about this relationship?

Diabetes Onset and Stress

Diabetes onset has been linked to emotional stress since at least the 17^th century, when one English physician attributed the development of diabetes to “prolonged sorrow.”¹

Various psychological states have been linked to diabetes onset, including high family stress,² work-related stress,³ and being a caregiver.⁴ Research has been hindered, though, by small studies and the difficulty in teasing out psychosocial stressors from other lifestyle factors important in diabetes development, like obesity and lack of exercise.

A recent large study, though, found job strain to be an independent risk factor for type 2 diabetes (T2DM), regardless of lifestyle factors. In the study, researchers pooled data from 124,808 adults from 13 European cohort studies. Over a follow-up of about 10 years, people with job strain had 11% higher likelihood of developing diabetes, compared to those without job strain (HR 1.11, 95% CI 1.00-1.23).⁵

Mechanistically speaking, psychological reactions to stress, such as defeatism or helplessness, can activate the hypothalamic-pituitary-adrenal (HPA) axis. Chronic activation of the fight or flight response via the HPA axis can, in turn, contribute to various endocrine abnormalities. High cortisol and low sex steroid levels antagonize the actions of insulin, contributing to stress hyperglycemia. Chronic HPA activation can also have an immunosuppressive effect, which can play a role in the regulation of inflammation.⁶

Diabetes Management and Stress

Stress can also exert indirect effects by interfering with diabetes self-care and management. Staying away from the holiday buffet can be socially isolating, while indulging in it can wreak havoc on blood glucose levels.

Diabetes-related distress is well documented and can affect self-care and glucose control. For example, in a cross-sectional study of 615 adult primary care patients in the US, diabetes distress was significantly associated with HbA1c (β = 0.43, CI: 0.14 to 0.72) and medication adherence (β = -0.58, CI: -0.91 to -0.25).⁷

Chronic emotional stress also represents a risk factor for depression, which is already more common among diabetics than the general population.⁸ Depression can affect activity levels, diet quality, medication adherence, and lead to unhealthy behaviors like smoking and alcohol, all of which may have negative consequences on glycemic control.

Stress and depression may also have a long-term impact on diabetes-related morbidity and mortality. A recent study of 22,003 middle-aged adults found that significantly more patients with diabetes had elevated stress and/or depressive symptoms, compared to those without diabetes (36.8% vs. 29.5%; P<0.001). Over a follow-up of almost six years, patients with diabetes and stress or depressive symptoms had 57% increased risk of stroke (HR 1.57 [95% CI 1.05, 2.33]), and 53% increased risk of cardiovascular death (1.53 [1.08, 2.17]). ⁹

Strategies for the Holidays and Beyond

Cognitive behavioral therapy (CBT), yoga, and various relaxation techniques have all been tried as a means to decrease stress levels in patients with diabetes.

Studies that have looked at the effects of stress management on glycemic control are limited, though, and have produced conflicting results.

For example, one study looked at 53 patients with T2DM who were randomly assigned to stress management (10 min. of diaphragmatic breathing and 15 min. of progressive muscle relaxation twice per day) vs. no stress management. At the end of eight weeks, perceived stress and HbA1c decreased significantly in the stress management group (P<0.05).¹⁰

Conversely, another randomized trial that included 139 patients with both T1DM and T2DM and low levels of emotional well-being randomized participants to mindfulness CBT or treatment as usual. At six months follow-up, those in the mindfulness CBT group had sustained reductions in perceived stress (P<0.001), anxiety (P<0.001), and some types of depressive symptoms (P=0.004). The two groups did not differ, though, regarding diabetes distress and HbA1c.¹¹

Nevertheless, minimizing stress certainly can’t hurt. Strategies for reducing stress during the holidays and beyond include:⁶

• Improve time management skills.

• Decrease troublesome noise levels when possible.

• Set self-management goals that are realistic, measurable, and achievable, such as: “I will exercise 20 minutes at 6PM each day on Mon, Wed, Fri, and Sat.

• Engage in less black and white thinking about whether goals have been achieved or not; reframe into how close one has come to achieving one’s goals.

• Identify the source of stress, then separate the source from one’s reaction to it.

Changing one’s response to stress can include thought-stopping or reflective techniques, relaxation techniques like breathing or meditation, distraction, going out with supportive friends, and engaging in pleasurable activities like a hobby. Sitting in front of the TV with a carton of Haagen Dazs, though, doesn’t count.

Take-home Points

• The holidays can be especially stressful for diabetes control.

• Emotional stress activates the HPA axis and has been linked to diabetes onset.

• Emotional stress can increase the risk for depression and has negative effects on diabetes control and self-management.

• Various stress management techniques exist for stress reduction in diabetic patients, though research is limited on how they impact glycemic control.

References:

1. Willis T. Pharmaceutice rationalis or an exercitation of the operations of medicines in human bodies. In The Works of Thomas Willis. London, Dring, Harper, Leigh, 1679.

2. Kisch ES. Stressful events and the onset of diabetes mellitus. Isr J Med Sci. 1985;21:356-358.

3. Huth C, et al. Job strain as a risk factor for the onset of type 2 diabetes mellitus: findings from the MONICA/KORA Augsburg cohort study. Psychosom Med. 2014 Sep;76(7):562-568.

4. Aschbacher K, et al. Chronic stress increases vulnerability to diet-related abdominal fat, oxidative stress, and metabolic risk. Psychoneuroendocrinology. 2014 Aug;46:14-22.

5. Nyberg ST, et al. Job strain as a risk factor for type 2 diabetes: a pooled analysis of 124,808 men and women. Diabetes Care. 2014 Aug;37(8):2268-2275.

6. Lloyd C, et al. Stress and diabetes: a review of the links. Diabetes Spectrum. 2005;18(2):121-127.

7. Walker RJ, et al. Independent effects of socioeconomic and psychological social determinants of health on self-care and outcomes in type 2 diabetes. Gen Hosp Psychiatry. 2014 Nov-Dec;36(6):662-668.

8. Pouwer F, et al. Does emotional stress cause type 2 diabetes mellitus? A review from the European Depression in Diabetes (EDID) Research Consortium. Discov Med. 2010 Feb;9(45):112-118.

9. Cummings DM, et al. Consequences of comorbidity of elevated stress and/or depressive symptoms and incident cardiovascular outcomes in diabetes: results from the REasons for the Geographic And Racial Differences in Stroke (REGARDS) Study. Diabetes Care. 2015 Nov 17. pii: dc151174.

10. Koloverou E, et al. Implementation of a stress management program in outpatients with type 2 diabetes mellitus: a randomized controlled trial. Hormones (Athens). 2014 Oct-Dec;13(4):509-518.

11. van Son J, et al. Mindfulness-based cognitive therapy for people with diabetes and emotional problems: long-term follow-up findings from the DiaMind randomized controlled trial. J Psychosom Res. 2014 Jul;77(1):81-84.