Stress is a person’s physical and emotional response to change or a perceived threat. Certain amounts of stress are normal, but excessive levels can be a risk factor for the development of diabetes and may complicate its treatment.
Stress comes from many sources. For example, major life events, such as a birth, job change or divorce, are common sources of stress. Other stressors include daily encounters such as heavy traffic, personal conflicts and workplace pressures. And factors such as toxins, viruses or certain medications can stress organs including the pancreas.
Stressful periods trigger the release of hormones by the endocrine system. These hormones prepare the body for an immediate “fight or flight” response, in which it either combats or flees from the perceived danger. The amount of glucose in the bloodstream increases in the presence of the hormones. Blood pressure and flow also increase to provide energy to the muscles. In addition, the stress-response hormones cause the suppression of the immune, digestive and other systems that are not immediately needed.
In the short term, stress can be a positive response. However, chronic stress may damage tissues and contribute to a variety of medical conditions. For people with diabetes, the stress response can impair control of glucose. Stress may also cause patients to make poor dietary choices and skip glucose checks and medications.
Stress management techniques including exercise, relaxation techniques, counseling and establishment of a sick-day plan can help patients control stress and diabetes.
About stress and diabetes
Stress has many affects on the body, including changes in the level of glucose (blood sugar). It can promote the development of, and complicate control of, diabetes.
Stress is the body’s emergency response to emotional and physical events. In reaction to stressful situations such as family conflict, a part of the brain called the hypothalamus signals the endocrine system to ready the body for a “fight or flight” response. This includes the release of stress hormones from the adrenal glands.
Adrenaline (also known as epinephrine) is the most prevalent hormone released during stressful periods. In the presence of adrenaline, there is an increase in glucose levels, heart rate and blood pressure. These responses allow more energy to be available to the cells to prepare the body to respond to the stressor (factor that causes stress).
Cortisol is the second major stress hormone released by the body. Much like adrenaline, it also raises glucose levels in response to crisis. In addition, cortisol suppresses body functions that are not immediately essential, such as the immune, digestive and reproductive systems.
Adrenaline, cortisol and other hormones cause the physical and emotional effects of stress on the body. Stress can be acute (short-term) or chronic in duration. In the short term, the presence of these hormones helps the body deal with the immediate stressor be acute (short-term) or chronic in duration. In the short term, the presence of these hormones helps the body deal with the immediate stressor.
The increased levels of glucose available due to stress can be used for energy during the immediate response to the stressor. However, hyperglycemia can result if the body does not use this glucose. Short-term stress in a diabetic patient may contribute to immediate hyperglycemic complications such as diabetic ketoacidosis. Chronic stress contributes to long-term complications such as high blood pressure and diabetic nephropathy.
The reactions to stress are not the same for all patients with diabetes. Some people with type 2 diabetes may be more sensitive to some stress hormones, which causes a greater effect on the body. Glucose levels may also change differently for various types of stress and different types of diabetes. Mental stress raises glucose in patients with type 2 diabetes and most with type 1 diabetes. However, the same stress can cause a decline in glucose for some people with type 1 diabetes. Glucose levels usually increase when patients with either type of diabetes are exposed to physical stress.
Stress may also be a factor in the development of diabetes. The causes of the various forms of diabetes are complex and not fully understood, but many factors may cause physiological stress to the pancreas. For example:
- Viruses may contribute to type 1 diabetes by stressing and destroying the beta cells, which produce the glucose-controlling hormone insulin.
- Insufficient sleep may be a risk factor for type 2 diabetes. And some research suggests that heavy consumption of sugar may over the long term stress the beta cells and increase the risk of type 2 diabetes.
- Hormones released during pregnancy can contribute to gestational diabetes.
- Many stressors ranging from pollutants to medications such as immunosuppressives may promote secondary diabetes.
Potential causes of stress
Different people will be affected by different types of changes, but common stressors (factors that cause stress) that may affect individuals with or without diabetes include:
- Life events. Events such as divorce or separation, death of a loved one, infertility or the birth of a child, moving, a major financial setback and employment changes are common stressors. Stress may also result from being the victim of or witnessing a crime or natural disaster.
- Daily events. Events such as traffic congestion, long commutes, working overtime, deadlines, personal conflicts, car trouble and juggling household chores and childcare can be stressful for many people.
- Environmental stressors. Common environmental stressors include pollution, weather extremes and excessive noise.
- Physical stressors. Injury, chronic pain or disease, tiring physical activity such as travel, fatigue, dehydration and unsatisfied physical needs such as lack of sleep can all induce stress. The effects of surgery and pregnancy may also be considered types of physical stress, and factors such as smoking or abuse of alcohol can stress the pancreas. Sick days, even those due to seemingly minor conditions as a yeast infection or a cold, can disrupt control of glucose.
There are also some characteristics that may impede a person’s ability to cope with change, causing them to experience more stress. These characteristics include:
- Genetic predisposition. Some inherited psychological factors can inhibit an individual’s ability to cope with change.
- Inability to adapt. Most people are eventually able to adapt more comfortably to a change, such as learning to drive on a particularly busy highway in the morning. However, some people never make this adjustment and each repeated event produces the same intense physical response.
- Inadequate relaxation response. The stress hormones of some people do not return to normal levels following an acute stress event. The elevated hormone levels cause prolonged wear and tear on the body. This is particularly common in highly competitive athletes and individuals with a history of major depression.
- Age. Both the young and the elderly tend to be more susceptible to stress than people of other age groups. Children are particularly susceptible because they often have little control over change and because they cannot communicate their feelings well enough to help manage stress. Seniors are susceptible because they are often exposed to multiple major stressors, such as the loss of a spouse, medical problems, financial worries and/or a change of living situation.
- Isolation. Individuals who lack a solid social network of friends and family are more likely to have trouble adjusting to change.
- Environment. Stress can be job-related. Interpersonal conflicts with others and office politics are just two examples. People with a high level of responsibility, such as air-traffic controllers, are also prone to stress.
Diabetes adds to the stressors and complicates the stress response of the patient. The diagnosis and management of the disease are likely to add to the patient’s everyday stresses. Self-care such as meal planning and preparation, glucose monitoring, foot care, skin care, exercise and managing multiple medications can take hours a day. Concern over the presence of possibility of complications such as diabetic neuropathy or diabetic retinopathy also increases stress.
Potential effects of stress
Stress can impact a patient’s ability to manage diabetes in several ways. Examples include:
- Poor compliance. Patients may get less exercise, fail to follow their prescribed diet, forget to take insulin or antidiabetic agents, forget to perform glucose monitoring or ketone tests, smoke or drink more alcohol. These actions may exacerbate stress levels and worsen a patient’s condition. In addition, people tend to crave carbohydrates such as sugar during periods of stress because they may temporarily increase levels of the neurotransmitter (brain chemical) serotonin and have a calming effect. However, these dietary choices can have serious consequences for patients with diabetes.
- Raised glucose levels. Increased glucose in the bloodstream is common during times of stress, and this hyperglycemia may have many negative consequences for patients with diabetes.
- Raised blood pressure and heart rate. People who undergo prolonged stress develop vasoconstriction, which raises their blood pressure and heart rate. This condition may lead to high blood pressure and cardiovascular conditions.
To help manage stress, patients may wish to log their stress level (on a scale of one to 10) with their glucose readings. After a couple of weeks, patients can compare how their glucose levels change in association with their degree of stress. Other stress management techniques range from physical activity to biofeedback to observance of a sick-day plan.
Managing stress begins with identifying stressors in a person’s life. A stressor is a factor that causes stress, and it can be positive and negative at the same time. For example, starting a job is usually a positive experience, but settling into new responsibilities can cause excessive stress.
In this example, the stressor is obvious. At other times, individuals may feel overstressed without knowing why. The more aware people are of potential stressors, the more effective they will be in controlling them.
Answering the following questions may help patients identify a pattern to their stress:
- What major life changes have occurred recently? These include illness, moving, changing jobs, unemployment, beginning or ending a relationship, marriage, pregnancy, conflict with others or loss of a loved one.
- Are time pressures contributing to stress? Time management, in professional and personal lives, is a major cause of stress. Management of diabetes including glucose monitoring, medication administration and other self-care add to the demands on a patient’s time. Often, people sacrifice personal time to fulfill obligations to family and work. Sooner or later, this imbalance may cause feelings of pressure and stress.
- How intense is the stress? The frequency, intensity and duration of stress may indicate its severity and cause. If stress levels skyrocket during work and drop when going home, the cause is likely related to work. If there is a constant nagging anxiety, the stress may have more subtle causes.
- Is lifestyle affecting the ability to handle stress? Lack of sleep is a possible cause of stress. Sleep helps the body recover from the day’s events and challenges. Maintaining good sleep habits and routines may also provide a sense of stability and reduce feelings of stress. Staying up late or frequent interruptions to sleep interfere with the ability to cope with stress. Lack of exercise may also contribute to stress and prevent the body from using excess glucose that has collected in the blood.
- Are eating habits a factor? A balanced diet developed with the patient’s healthcare team can help manage diabetes and reduce stress. Maintaining consistency in the amount of food eaten and the amount of insulin or other medication taken at regular times of the day is important for controlling glucose. Conversely, a poor diet and erratic eating schedule can put the body under physical stress, making it harder for someone to deal with stressful situations, as well as contribute to glucose fluctuations.
- Is physical health contributing to stress? Pain and discomfort are stressors. Illness and injury put the body under physical stress, which, in turn, can cause emotional stress. Emotional stress is often perceived as a physical discomfort, such as stomach cramps.
- How is stress being dealt with? Everyone has different coping styles. Some people can minimize the effect of stress by looking for solutions to problems or minimize the importance of the stressful situation. Other coping mechanisms, such as smoking cigarettes or abusing alcohol or drugs, may contribute to stress and impair control of glucose.
It may be helpful to keep a daily log of activities and note which events trigger stress. Patients with diabetes may also record their glucose readings as part of the log. After a week or two, they can examine the log for any patterns in stressors and glucose levels. This can help patients understand their sources of stress and better plan for resulting glucose changes. If the patient feels stress but is unable to identify causes, counseling may help identify the hidden stressors in one’s life.
Once the causes of excess stress have been identified, people can take action to address or eliminate the stressor. For example, people who are constantly under workplace stress due to a demanding boss may ask to be transferred, have their duties changed or look for a new job.
In some cases, the source of the stress cannot be eliminated, no matter what a person does. This is the case with stress caused by caring for a loved one who is ill or managing a chronic disease such a diabetes. In these cases, certain coping skills may help.
Healthy coping strategies for stress include relaxation, regular exercise, communication, social support and education. Getting enough sleep is another important component to managing stress. Being organized and prepared may also help eliminate surprises or stressful situations – for example, allowing ample travel time may help reduce the stress of getting stuck in traffic. A combination of strategies may be best to manage stress.
Relaxation is any means of limiting activity to reduce stress levels in the body. Examples of ways some people relax include taking a walk, listening to music or an inspirational tape or talking with a friend or family member. People can also practice specific activities designed to relax the body and mind, such as meditation, progressive relaxation, breathing exercises, visualization, guided imagery or biofeedback.
Regular physical activity can help patients relieve stress and manage glucose. In patients who exercise often, the body releases smaller amounts of hormones in response to stress. Exercise also strengthens the heart and other muscles, which in turn helps them to be better prepared for the increases in blood pressure and heart rate that occur during stressful situations. Types of exercise include:
- Aerobic exercise. Activities such as walking and bicycling promote cardiovascular health and are especially helpful in reducing stress.
- Stretching. This is gentle on the body, increases flexibility and can reduce muscle tension and stress.
- Strengthening. Lifting weights or using weight machines can constructively channel aggressive impulses.
For reasons including the complex interactions of exercise and blood sugar, patients with diabetes are urged to consult their physician before starting an exercise program. To stick with the plan, it may help to request a specific prescription for exercise.
Diabetic patients can also ask their physician to create a sick-day plan for them and request tips on managing multiple medications, such as using a timer or pill organizer.
Healthy communication can be effective in relieving stress. Some patients find talking to the diabetes care team difficult, but strategies such as making a list of questions in advance can help.
A healthy social network, including family, friends and the community (e.g., religious and social organizations), is also important. Guidelines on managing diabetes seldom mention that socializing can help prevent or control diabetes by reducing stress, according to the International Diabetes Federation. Diabetes support groups can help patients may feel better just knowing that others are experiencing similar situations, and they may learn coping tips from others.
In addition to social support, self-communication may also help alleviate stress. Expressive writing, in the form of a stress journal or a diary, can ease stress.
Attitude is also important. People who adopt a problem-solving mode, as well as those who attempt to downplay the significance of the stressor, can usually reduce stress levels.
People who feel overwhelmed by stress may engage in unhealthy coping methods, such as blaming others, isolating themselves or acting aggressively. They may benefit from professional counseling. A mental health professional such as a psychiatrist, psychologist, marriage and family therapist or licensed social worker can teach a person how to identify stress and develop appropriate coping and problem-solving skills. In some cases, medications such as anti-anxiety drugs or antidepressants may be prescribed. For patients who need antidepressants, an additional benefit is that some of these medications also reduce the physical pain of conditions including diabetic neuropathy.
Education can also be an effective stress management tool. The American Diabetes Association and local medical groups offer classes and literature about managing diabetes. This information can help patients become more aware of what diabetes is, how it affects their bodies and how to prevent it from overwhelming them. Other educational opportunities, such as assertiveness training or anger management, can also help patients cope with stressors in their lives.
Questions for your doctor
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about stress and diabetes:
- What signs may indicate that stress is affecting my diabetes management?
- Could stress have contributed to the development of my diabetes or prediabetes?
- Will stress make my diabetes worse?
- Can I predict how stress will change my glucose levels?
- How should I alter my diabetes treatment in response to my stress level?
- What other changes should I make during stressful periods?
- Should I take medication to help reduce my stress? If so, what are the side effects and risks of these drugs? Are there any risks of I don’t take medication?
- How will taking medication to reduce stress affect my diabetes treatment regimen?
- Can you recommend a support group to help me deal with the stresses of having diabetes?
- Will reducing my stress help treat my diabetes?