Dutch study finds stress increases risk of diabetes

Coping with stress is key element in diabetes care

Psychological stress contributes to physiological stress, which significantly increases the risk of developing diabetes, say Dutch researchers in a study published in the February issue of Diabetes Care.

More than 2,000 white adults between the ages of 50 and 74 were asked about stressful life events over the past five years, and their answers were correlated with the number of patients who later developed diabetes.

Previously healthy adults who experienced three or more highly stressful events over a five-year period were 60% more likely to be diagnosed with Type 2 diabetes than those with fewer stressful events, wrote lead researcher Johanna Mooy, MD, PhD, and colleagues at the Institute for Extramural Medicine at Vrije Universiteit in Amsterdam. The risks remained even after Mooy’s team factored out family history of diabetes, lack of exercise, and alcohol use.

While other evidence suggests that stress may trigger weight gain in the abdomen, which also is a risk factor for diabetes, the Dutch researchers found no link between stress, abdominal fat, and diabetes. They also found no specific association with stress connected to work-related events such as forced job changes, retirement, or long-lasting problems at work.

The researchers theorized the link is caused by increasing levels of the hormone cortisol and decreasing levels of sex hormones such as testosterone, which have been shown to influence the action of insulin. The study also raises the issue of whether people who are stressed make poor health choices and thereby increase their risk of developing diabetes or if there is a causal connection between stress and diabetes.

U.S. diabetes experts weren’t surprised at the findings, but they say the strong correlation between stress and diabetes should serve as a warning signal to clinicians to help already-diagnosed patients with diabetes to cope better with stress.

"Stress management should be part of every diabetes care program, but unfortunately, very few clinics or hospitals pay attention to the effects of stress on patients with diabetes," says Sarah Cook, RN, a psychiatric and mental health nurse at St. Joseph’s Hospital in Towson, MD.

Cook offers a stress management seminar every six weeks as part of the hospital’s diabetes management program. "I encourage repeat attendance because dealing with diabetes can become more difficult over time for many people." Having diabetes and learning to manage the disease is in itself a powerful stressor, says Cook. "When you add in the stresses of everyday life, it can become overwhelming."

Experts denote several major causes of stress for patients with diabetes:

• fear, frustration, and anger associated with the diagnosis and unending attention the disease demands as well as the fear of complications, which may develop in coming years;

• lack of support from friends and family;

• lack of education about ways to manage the disease and the resulting emotional stress of not knowing what is happening and what to do about it;

• lack of adequate support from a diabetes care team;

• physiological stress associated with poor eating and exercise habits that can result in episodes of hyperglycemia and hypoglycemia.

"High stress levels can cause the release of cortisol, the fight-or-flight hormone, which speeds up metabolism and causes insulin to be absorbed prematurely, and causing a floating blood sugar that doesn’t cover the medications a patient may be taking," Cook explains.

She recommends several stress management techniques to her patients, but one of the most effective is keeping a journal. "I ask them to record their sugars and their feelings. Many of them begin to see a pattern then."

She recalls an elderly woman with diabetes who was under excellent control, with fasting blood glucose around 100 mg/dL. "Suddenly her sugar shot up to 300 in a 24-hour period, and she couldn’t figure out a reason why. We took her back step-by-step through the last 24 hours and she finally recalled something she had almost forgotten — at least on the conscious level. There had been a fire alarm in her apartment building, and she was evacuated briefly. The stress of not knowing whether she would lose her home and all her possessions caused this kind of blood glucose response."

"You can see how collectively destructive stress can be," says Cook. "That’s why stabilizing their lifestyles is so important to help patients control their diabetes."

She recommends asking patients to look at the symptoms that indicate stress may be playing a role in their diabetes control. The most common symptoms are:

• agitation;

• anxiety;

• sleep loss or change in sleep habits;

• change in eating habits — either eating more or less than normal;

• lack of compliance — failure to eat or take medications on time;

• lack of concentration;

• low self-esteem;

• irritability;

• talking too much or withdrawal;

• frequent crying;

• headaches;

• dizzy spells;

• digestive problems;

• depression.

Of these, Cook says depression is the hardest one to pin down. "It’s so complicated and manifests itself in so many ways; it’s hard to tell where stress ends and depression begins."

Helping patients recognize issues

To clinicians, Cook advises helping patients recognize their "issues," whether those issues are with diabetes or with their everyday lives. "Watch their body language, and it will tell you a great deal about what is going on with them." People under stress may frown, clench their fists, grind their teeth, perch on the edge of their chairs, and drive very aggressively or grip the steering wheel very tightly. Cook has devised a pamphlet for patients, which includes tools on how to recognize stress and how to relieve it.

She first gives patients a psychological stress test, which scores the impact of stressors on their lives. Events range from ones usually viewed as negative — the death of a loved one, the loss of a job, or even a move to a new home — to events usually perceived as positive, such as a marriage, the birth of a child, or a job promotion. When patients see their stress scores and add in a value related to being diagnosed with a chronic disease, they begin to understand how important it is to acquire the tools to learn to relax, she says. (See "Stressful Events" and "Stress Reducers," at left.)

She uses a variety of techniques depending on each individual patient’s need ranging from simple relaxation techniques to organizational and time management skills to breathing techniques and even meditation. "Good nutrition and a regular exercise program, even if is only chair exercise, will go a long way toward relieving stress," Cook says.

One of the biggest stress relievers is to help patients recognize their limits. "I try to help them get a realistic view of what they can do and the events that are not under their control," she says. "I tell them not to judge themselves by others’ standards." Cook advises providers to "encourage an optimistic point of view. Negativity complicates life."

Stress probably plays a role in the rising number of cases of diabetes, says Marion Parrott, MD, vice president for clinical affairs for the American Diabetes Association in Alexandria, VA. "We have been seeing a huge increase in the number of cases of diabetes in this country, and the increase in obesity and the decrease in physical activity somehow don’t seem adequate to explain the increases we are seeing.

"Stress has always been known to be an aggravating factor in diabetes, and stress isn’t fun. It’s sure not good for you, but it’s still not certain if reducing stress would reduce the incidence of diabetes," Parrott adds.

Is depression a link?

Recent studies that show that depression may be a triggering factor for diabetes, Parrott says. "Maybe depression is the link between stress and diabetes. It’s an interesting idea."

Patients who are stressed exercise less and eat more and put on more visceral fat, even if they have not been diagnosed with diabetes, so it all seems to lead to the same conclusion, she says.

Members of diabetes care teams can help their patients by recognizing that most people think their lives are more complicated than those of our ancestors, Parrott says. Most of us also believe we are more overwhelmed by our lives than our parents or grandparents and that we live at a more hectic pace.

The stresses of previous generations may be relative and it may not be fair to compare modern life to the stress of life during the Depression or during wartime, she points out. But there are enormous stresses today that didn’t exist a generation or two ago. "My parents didn’t worry about somebody going to their kids’ school and shooting the place up," she says.

Giving patients the tools to cope with that sense of overwhelm just might help them achieve better glycemic control and ultimately prevent or delay complications, Parrott adds.

Stressful Events
- Death of a spouse
- Divorce
- Marital separation
- Detention in jail or other institution
- Death of close family member
- Major personal injury or illness
- Marriage
- Losing a job
- Retirement
- Major change in health or behavior of a family member
- Pregnancy
- Sexual difficulties
- Birth of a child
- Financial crisis
- Death of a close friend
- Change of job
- Incurring debt for a major purchase
- Major change in job responsibilities or hours worked
- Outstanding personal achievement
- Change in residence

Stress Reducers
- Taking time for yourself every day
-Planning your day, getting organized
- Talking to a friend or spouse about your feelings
- Developing a positive attitude
- Getting as much fresh air as possible during the day
- Exercising on a regular basis
- Practicing breathing exercises or meditation
- Practicing yoga
- Listening to soothing music, especially at bedtime
- Enjoying a hobby or involving yourself in volunteer work
- Avoiding excess alcohol consumption
- Avoiding caffeine late in the day
- Eating lightly in the evening
- Getting plenty of sleep
- Saying no to responsibilities you don’t want or need
Source for both lists: St. Joseph’s Hospital, Towson, MD.

[Contact Sarah Cook at (410) 337-1580 and Marion Parrott at (703) 549-1500.]