Stress Plays Role in Diabetes Control

June 21, 1999

NEW YORK (Reuters Health)--Stress can upset a diabetic's management of his or her condition, researchers report. They say patients with type one (insulin dependent) diabetes appear to be at highest risk from stress-related lapses in care.

"Diabetes control can be exquisitely sensitive to small variations in stress and self-management behavior," explain researchers led by Dr. Mark Peyrot of the Loyola College Center for Social and Community Research, Baltimore, Maryland. The findings are published in the June issue of The Journal of Health and Social Behavior.

In type one diabetes - the form of the disease affecting about 10 percent of all diabetics - the pancreas is unable to secrete insulin, the hormone that regulates levels of sugars within the blood. These patients need to have regular injections of insulin. The majority of diabetics have type two diabetes, in which cells become insensitive to the effects of insulin. To compensate for this insensitivity, the pancreas gradually increases its production of insulin. However, in most cases insulin production eventually fails to meet the body's demands.

Diabetics must carefully regulate their energy expenditure, food intake, and medications to keep blood sugar levels within safe, normal levels.

Peyrot's team examined the behaviors, personalities, and blood sugar levels of 57 type one diabetics and 61 type two diabetics to determine the relationship between psychological stress and blood sugar control. Study participants were divided into two groups based on personality - effective, “self-controlling” stress-managers, and more reactive “emotional” types.

The authors report that among type one diabetics, relatively "self-controlling persons had better glycemic (blood sugar) control and emotional persons had worse."

The researchers explain that "when patients are stressed they have difficulty maintaining their self-care regimens."

The team also found that "self-controlling" type two diabetics had better glycemic control than their "emotional" peers, but in contrast to type one diabetics, ability to follow treatment was not the main reason for this difference.

Patients with type two diabetes may be better able to handle stress-related lapses in care, the researchers speculate, since their pancreas maintains the ability to produce insulin. On the other hand, stressful situations may be especially dangerous for individuals with type one diabetes, who lack this physiologic “safety net.”

"In type two diabetes, the body's ability to automatically manage its own affairs is impaired," the authors explain, "but it remains partially intact. In type one diabetes, the body becomes a machine which must be operated (more) carefully." Patients with type one diabetes are therefore much more vulnerable to stress-related lapses in blood sugar maintenance, and "failure to attend to these matters can have disastrous consequences," Peyrot and colleagues conclude.

Stress in middle-age ups diabetes risk

February 22, 2000

NEW YORK (Reuters Health) -- Psychological stress caused by the death of a spouse, a financial crisis or other life-altering event may increase the risk of developing diabetes in middle age, a team of Dutch researchers report.

Their study found that these types of major life events were associated with type 2 diabetes regardless of family history of the disease, exercise or alcohol use. Type 2 diabetes usually occurs later in life, and in many cases can be controlled with diet and exercise.

"A high number of rather common major life events that probably indicate chronic psychological stress during the past 5 years was indeed related to a higher prevalence of previously unknown type 2 diabetes," conclude Dr. Johanna Mooy and colleagues with the Vrije Universiteit in Amsterdam, and colleagues. Their study is published in the February issue of Diabetes Care.

The researchers asked more than 2,000 white adults between 50 and 74 years about stressful life events in the past five years, such as the death of a loved one, the end of a relationship or long-lasting financial problems.

Diabetes was diagnosed in 5% of people participating in the study and those with the highest number of stressful events (three or more) were 60% more likely to have diabetes as those with fewer stressful life events.

However, there was no association between stressful work-related events such as a forced job change, retirement or long-lasting problems at work, the study found.

The study could not conclusively determine that stress causes diabetes. However, the researchers believe that it is unlikely that the diabetes was the cause of the stress, or that some underlying factor -- such as poverty -- contributed to both conditions.

The authors conclude that the findings are at least "partially consistent" with a theory that says that stressful life events increase the diabetes risk by increasing levels of the hormone cortisol and decreasing levels of sex steroids such as testosterone, which have been shown to influence the action of insulin. Insulin is the hormone that regulates blood sugar.<,p>

Although that theory suggests that stress results in a higher diabetes risk due to weight gain in the abdomen, the researchers found no link between stress, abdominal fat and diabetes.

Marital Strife May Hike Diabetes Risk

Stress linked to elevated glucose levels

The study suggests people in high-stress marriages are twice as likely to develop diabetes as contented couples.

By Jacqueline Stenson, MSNBC

SAN ANTONIO, June 10 — Married people who squabble more than they smooch may be at risk for something other than divorce court. A study presented here Saturday found that those with high marital stress were twice as likely to develop diabetes as contented couples.

STUDY AUTHOR Sharon Gaskill Fowler, a public health researcher at the University of Texas Health Science Center in San Antonio, said the new findings are in line with recent studies in both animals and humans suggesting that stress can raise levels of glucose, or blood sugar.

Elevated glucose levels are a hallmark of type 2 diabetes, the form of the disease that accounts for 90 percent of the 16 million diabetes cases in the United States and is a leading contributor to kidney failure, blindness and heart disease. Type 2 diabetes is on the rise in America, mostly because of increasing obesity and sedentary behavior, experts say.

“Our data suggest that it’s not enough, in the prevention and treatment of diabetes, to look only at such factors as glucose levels and weight,” Fowler said at the annual meeting of the American Diabetes Association. “The stress people are under may affect whether they will go on to develop diabetes and, if they do develop it, how well they will keep it under control.”

She noted that previous studies have found that in people who already have diabetes, blood glucose levels can escalate during periods of stress.

Dr. Gerald Bernstein, an endocrinologist at Beth Israel Medical Center in New York and a past president of the American Diabetes Association, said it would be inaccurate to conclude from this study that stress directly causes diabetes.

Rather, he said, stress is one factor that may accelerate development of the disease in high-risk individuals, such as those who are overweight or have a family history of the disease. He said stress may spur production of adrenaline and cortisol, hormones that can impair the action of insulin, the hormone that allows cells to convert glucose to energy. If insulin can’t do its job, blood glucose levels rise.

STUDY DETAILS

From 1984 to 1988, Fowler and colleagues involved with the San Antonio Heart Study examined 1,733 married, non-diabetic Mexican Americans and non-Hispanic whites ages 25 to 64.

Tests at the beginning of the study included blood sampling for diabetes and standardized questionnaires for various types of stress, including that of marriage. Participants were asked to think about their lives with their marriage partners and to score how often they felt various ways, such as annoyed, tense, bored, angry, worried, neglected, contented, relaxed and unhappy.

Type 1 diabetes is an autoimmune disease that destroys the body's ability to produce insulin, a hormone that helps the body stash various nutrients in cells. This form of the disease, which most often develops in childhood, accounts for 5 to 10 percent of cases.

Type 2 diabetes usually develops in adulthood and is caused by either the body's inability to make enough, or to effectively use, insulin. This form of diabetes accounts for 90 to 95 percent of cases.

Women can develop a form of type 2 diabetes during pregnancy called gestational diabetes. Approximately 40 percent of women with gestational diabetes who are obese before pregnancy develop type 2 diabetes within four years.

1. Frequent urination
2. Constant sensation of thirst
3. Unexplained weight loss
4. Extreme hunger
5. Sudden vision changes
6. Tingling or numbness in the hands or feet
7. Extreme fatigue
8. Slow healing sores
9. Frequent infections

People are more likely to develop diabetes if they are obese or have a family history of the disorder. And as age increases, so does the risk of diabetes. In addition, certain groups are at increased risk for diabetes, including blacks, Hispanics and Native Americans.

Some cases cannot be prevented. However, maintaining a healthy weight and exercising regularly may help protect against the development of type 2 diabetes in many people. The American Diabetes Association recommends blood glucose screenings beginning at age 45, or younger if someone has a family history of diabetes, is obese or has other risk factors.

At least a third of people with type 2 diabetes go untreated because they don’t know they have the condition. Many of these people will be diagnosed with diabetes only after they have developed serious complications, such as heart attack, kidney disease or impaired eyesight.

People with type 1 diabetes must take daily insulin shots to live and are advised to carefully watch their diets.

People with type 2 diabetes may be able to control their blood sugar through diet and exercise. Others may need to take oral diabetes medicines to lower their blood glucose levels. If this doesn't work, insulin may be necessary.

Source: American Diabetes Association

At the follow-up period eight years later, blood tests revealed that 18 percent of those in the group with high marital stress (15 percent of the total population) had developed type 2 diabetes, compared with 9 percent in the low-stress group.

“There was a doubling in the incidence of diabetes among those in the high-stress group,” Fowler said.

Overall, 11 percent of the population developed diabetes during the study period.

Even when the researchers accounted for the effects of a family history of diabetes, obesity, high blood pressure and other factors known to be associated with the development of diabetes, marital stress remained an independent risk factor.

And while the study also looked at the impact of overall daily stress and job stress, only marital stress was a predictor of the disease. “All three types showed some increase in diabetes, but only marital stress was clinically significant,” Fowler said.

She said other types of stress probably also contribute to diabetes but that perhaps the questionnaires used to assess these types of stress were not sufficient.

On the other hand, she said, marital stress may have a larger impact because it is essentially ever-present. “When you go home, you can leave your work stress behind,” she said. “But marital stress hits closer to the bone.”

DOWNSIDE OF DIVORCE

Fowler stressed that divorce is not necessarily the answer to better health.

“One of the messages we don’t want people to take away from this study is that if they are in a high-stress marriage they should jettison the marriage to save their blood glucose,” she said. “Our data suggest that working to improve and heal the marriage and working to improve on other risk factors would be a good strategy.”

Fowler, who was married just six days ago, said the study findings didn’t deter her plans to wed. In fact, she said marriage generally seems to keep people healthy. In her study, people who became separated, divorced or widowed during the study period were 30 percent more likely to develop diabetes than the others.