Stress Management for Diabetics

The effects of stress on blood sugar levels is an often-overlooked factor in the management of diabetes.  Diabetics are known to have a higher prevalence of anxiety than the general population and are statistically twice as likely to develop depression[1]. But when stressors are properly assessed and addressed, stress management can have profoundly beneficial effects on disease course and outcomes.

Some of the most common manifestations of stress can themselves cause cortisol levels to rise. Common physiologic effects include headaches, muscle tension, poor quality sleep, fatigue, and memory and concentration problems. Emotional and behavioral effects often manifest as irritability, restlessness, anxiety, lack of motivation, social withdrawal, angry outbursts, eating too much or too little, and excessive alcohol consumption. These effects further complicate diabetes management.

And while the causes of stress both related and unrelated to diabetes vary widely and range from physical to psychosocial, the physiological impacts of stress are universal, indicating the need for a multi-faceted approach to stress management and mitigation.

Causes of Stress in Diabetics

Diabetics are subject to disease-specific mental and emotional stressors that may include actual and perceived restrictions around the diabetes regimen, stressful physician-patient dynamics, and anxiety about disease progression, all of which lead to elevated cortisol and blood glucose levels. Compounding disease-related stress is the potential for a cycle of negative reinforcement resulting in decreased compliance and poor glycemic control[2]. Additionally, accidents and injuries, occasional bouts of illnesses such as colds and flu, and taking over-the-counter cold and flu medicines can raise cortisol levels.

The Physiology of Stress

Biomarkers for stress are readily detected and quantified. Mental and emotional stress raises cortisol levels and mobilizes glucose into the bloodstream. Acute bouts of severe psychological stress have been shown to suppress β cell function and insulin sensitivity[3]. Increased cortisol levels also raise blood sugar levels by stimulating appetite, leading to overeating. Combined with emotional, or “comfort” eating in response to stress, this can lead some diabetics to eat more fatty or sugary foods.

Catecholamines released during the stress response exert immune effects that promote autoimmune development and are thought to play a contributory and/or causative role in type 1 diabetes[3]. Catecholamines prompt immune cells to secrete pro-inflammatory cytokines and also impair adaptive immunity by inhibiting production of interferon-γ and helper T cells[3].

Reducing Mental and Emotional Stressors

Diabetes is a challenging chronic health condition that invites patients to explore new and different behavioral, cognitive, organizational, and coping skills as tools to help them manage their health. A panoply of stress-reducing techniques and behavioral adaptations proven to effectively reduce cortisol and blood sugar levels is available. The key to success is to match the best method or methods for each patient’s individual needs.

In a 2017 study, the use of a mindfulness-based stress reduction (MBSR) program developed by Jon Kabat-Zinn reduced HbA1C levels in a group of type 2 diabetics by 8.7%[2]. This practice uses present moment mindfulness, nonjudgmental awareness, and acceptance of experience with an emphasis on openness and curiosity. In addition to significantly improving blood sugar control MBSR has been found to reduce depression and anxiety and improve measures of self-compassion. [2].

Problem-focused coping styles have been found to be positively associated with better psychological and physical health in type 2 diabetics, as opposed to negative coping styles, such as resignation, protest, or isolation. Interventions that have been found to improve coping skills in diabetics include diabetes education and support groups, and those that improve problem-solving and cognitive restructuring skills to promote practical solutions, such as self-management programs and cognitive behavioral therapy[1].

Other proven stress reduction practices include meditation, yoga, visualization, affirmative self-talk, self-acceptance, psychological counseling, and recreational exercise. Additionally, for some individuals, improving organizational skills around medication and supplement schedules and meal planning can help reduce stress by improving compliance and avoiding binge eating or stress eating.

Ayurvedic Herbs

A variety of ayurvedic medicinal herbs improve the body’s ability to maintain physiological homeostasis in the presence of stressors. Some are used primarily for this purpose while others have been found to have secondary stress-reducing activity in addition to their primary effects.

  • Holy basil, also commonly known as tulsi, is traditionally used for stress reduction in ayurvedic medicine. Holy basil was found to inhibit cortisol release by up to 89% and block a receptor for corticotrophin-releasing hormone in a laboratory animal experiment[4].
  • Bacopa monnieri is regarded as an anxiolytic, antidepressant, sedative, and adaptogenic herb. In a clinical trial bacopa improved mood and reduced cortisol levels in healthy volunteers within one to two hours following a single dose[7].
  • Centella Asiatica, commonly known as gotu kola, is widely used to enhance cognitive function and has also demonstrated anti-stress, antidepressant, and anxiolytic properties in preclinical studies[8]. Specifically, gotu kola has been shown to increase alertness and decrease anger within one hour following ingestion[8].
  • Curcumin used widely for its anti-inflammatory benefits, has also been found to decrease elevated levels of cortisol associated with chronic stress and depression. In a clinical trial, 6 weeks of supplementation with curcumin significantly increased levels of brain-derived neurotrophic factor and decreased circulation cortisol and inflammatory cytokine levels, suppressing activation of the hypothalamic-pituitary axis (HPA)[9].
  • Momordica charantia inhibits the enzyme cortisone reductase, which converts cortisone to cortisol in the liver, adipose, and central nervous system and has been identified as an important enzyme contributing to the development of obesity and type 2 diabetes[10].
  • Fenugreek contains the branched-chain amino acid 4-hydroxy-isoleucine (4-HI) which may prevent activation of the HPA axis. In preliminary research, the amino acid was shown to decrease anxiety and depression-related behaviors in laboratory animals leading researchers to postulate that dietary deficiencies of 4-HI may be a predisposing factor[11].
  • Tinospora cordifolia has been found to decrease stress-induced elevated cortisol levels caused by chronic and heavy alcohol consumption and also helps normalize fatty acid metabolism by inhibiting cholesterol synthesis[12].

Diabetics are subject to a range of disease-associated forms of stress including lifestyle changes necessary for managing this challenging condition and concerns about potential disease progression. As a result, diabetics experience depression and anxiety at higher rates than the general population. These stressors compound the physiologic effects of diabetes and further impair blood sugar control.

Identifying and addressing each patient’s stressors on an individual basis can significantly improve overall disease management and, in some instances, may be the missing link to effective blood sugar control. Numerous behavioral therapies and methods for improving organizational and coping skills have proven effective stress management tools for diabetics. Additionally, a variety of medicinal herbs have demonstrated cortisol-lowering effects and can serve as adjunctive support.

References

1.           A systematic review of the relationships among psychosocial factors and coping in adults with type 2 diabetes mellitus. Int J Nurs Sci, 2019. 6(4): p. 468-477
https://pubmed.ncbi.nlm.nih.gov/31728402/

2.           Reducing diabetes distress and improving self-management with mindfulness. Soc Work Health Care, 2018. 57(1): p. 48-65   
https://pubmed.ncbi.nlm.nih.gov/29064772/

3.           Psychological stress and type 1 diabetes mellitus: what is the link? Expert Rev Clin Immunol, 2018. 14(12): p. 1081-1088  
https://pubmed.ncbi.nlm.nih.gov/30336709/

4.           Anti-stress Activity of Ocimum sanctum: Possible Effects on Hypothalamic-Pituitary-Adrenal Axis. Phytother Res, 2016. 30(5): p. 805-14
https://pubmed.ncbi.nlm.nih.gov/26899341/

5.           Adaptogenic and Anxiolytic Effects of Ashwagandha Root Extract in Healthy Adults: A Double-blind, Randomized, Placebo-controlled Clinical Study. Cureus, 2019. 11(12): p. e6466    
https://pubmed.ncbi.nlm.nih.gov/32021735/

6.           Body Weight Management in Adults Under Chronic Stress Through Treatment With Ashwagandha Root Extract: A Double-Blind, Randomized, Placebo-Controlled Trial. J Evid Based Complementary Altern Med, 2017. 22(1): p. 96-106      

7.           An acute, double-blind, placebo-controlled cross-over study of 320 mg and 640 mg doses of Bacopa monnieri (CDRI 08) on multitasking stress reactivity and mood. Phytother Res, 2014. 28(4): p. 551-9 https://pubmed.ncbi.nlm.nih.gov/23788517/

8.           Effects of Centella asiatica (L.) Urb. on cognitive function and mood related outcomes: A Systematic Review and Meta-analysis. Sci Rep, 2017. 7(1): p. 10646
https://pubmed.ncbi.nlm.nih.gov/28878245/

9.           Chronic Supplementation of Curcumin Enhances the Efficacy of Antidepressants in Major Depressive Disorder: A Randomized, Double-Blind, Placebo-Controlled Pilot Study. J Clin Psychopharmacol, 2015. 35(4): p. 406-10 
https://pubmed.ncbi.nlm.nih.gov/26066335/

10.         Momordica charantia extract, a herbal remedy for type 2 diabetes, contains a specific 11β-hydroxysteroid dehydrogenase type 1 inhibitor. J Steroid Biochem Mol Biol, 2012. 128(1-2): p. 51-5    https://pubmed.ncbi.nlm.nih.gov/22001161/

11.      Effects of 4-hydroxyisoleucine from Fenugreek Seeds on Depression-like Behavior in Socially Isolated Olfactory Bulbectomized Rats. Pharmacogn Mag, 2015. 11(Suppl 3): p. S388- 96 https://pubmed.ncbi.nlm.nih.gov/26929572/

12.         Moderate alcohol consumption in chronic form enhances the synthesis of cholesterol and C-21 steroid hormones, while treatment with Tinospora cordifolia modulate these events in men. Steroids, 2016. 114: p. 68-77 
https://pubmed.ncbi.nlm.nih.gov/26066335/

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