Diabetes and Stress: A Review

Abstract

Stress is a part and parcel of modern day life. Stressors may be internal and external. Our body responds to stress either as fight or flight response and repeated stress may lead to failing rheostat phenomenon of hypothalamus leading to less efficient hormonal control through feed-backs. This leads to various changes in body functioning at various levels like cellular, organic or systemic and finally leads to various diseases. Diabetes may be an outcome of stress and further sets in a vicious cycle of stress-diabetes relationship. Stress coping mechanisms are many and it depends on resources available with a wide range of personal variations.

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© Kamla-Raj 2008 Ethno-Med., 2(2): 131-135 (2008)
Diabetes and Stress: A Review
Analava Mitra
School of Medical Science and Technology, Indian Institute of Technology, Kharagpur 721 30,
West Bengal, India
Telephone: 91-322-282220/282657(R), Fax: 91-322-282221
E-mail: amitra@adm.iitkgp.ernet.in
KEYWORDS Stress; diabetes; fight or flight response; fast-paced society
ABSTRACT Stress is a part and parcel of modern day life. Stressors may be internal and external. Our body responds
to stress either as fight or flight response and repeated stress may lead to failing rheostat phenomenon of hypothalamus
leading to less efficient hormonal control through feed-backs. This leads to various changes in body functioning at
various levels like cellular, organic or systemic and finally leads to various diseases. Diabetes may be an outcome of
stress and further sets in a vicious cycle of stress-diabetes relationship. Stress coping mechanisms are many and it
depends on resources available with a wide range of personal variations.
INTRODUCTION
Definition of Stress and Stressors
It’s hard to dispute that most of us live life at
breakneck speed. It’s the nature of a fast-paced
society, where numerous family, social, and work
obligations can easily overpower precious time
and resources. But for people with diabetes both
physical and emotional stress can take a greater
toll on health. Stress is a feeling that’s created
when one reacts to particular events. It’s the
body’s way of rising to a challenge and preparing
to meet a tough situation with focus, strength,
stamina, and heightened alertness. Stress results
when something causes the body to behave as if
it were under attack. The events that provoke
stress are called stressors, and they cover a whole
range of situations like physical, injury or illness.
Or they can be mental, like problems in marriage,
job, health, or finances (Meadows-Oliver et al.,
2007).
Definition of Diabetes
The oxford dictionary defines diabetes as an
increase in urination and presently two types of
diabetes are known-diabetes mellitus, that is,
diabetes due to metabolic causes and diabetes
insipidus, that is, diabetes due to pituitary
dysfunctions. Diabetes mellitus being more
common and literally means diabetes until
classified otherwise. Of the various types of
diabetes two types are more common- Type 1 and
Type 2. Type 2 diabetes or commonly known as
maturity onset diabetes accounts for 80% of
diabetic populations in most countries. Hence
diabetes when unclassified means Type 2
diabetes.
U.S. Public Health Survey Estimate of Stress
A U.S. Public Health Survey estimated that 70
percent to 80 percent of Americans experience at
least “some stress” every two weeks and visit a
physician each year for a stress-related disorder.
Job-related stress costs U.S. businesses $60
million annually (DiClemente, 2006).
Fight-or-Flight Response
The body gears up to take action in response
to stress. This preparation is called the fight-or-
flight response (ADA, 2007). Repeated stress may
lead to failing rheostat phenomenon of
hypothalamus leading to less efficient hormonal
control through feed-back mechanisms (Dilman,
1986).
Endocrine Changes
In the fight-or-flight response, levels of many
hormones shoot up. The hypothalamus signals
the adrenal glands to produce more of the
hormones catecholamines and cortisol and also
stimulate pituitary gland to produce more growth
hormone and release them into the bloodstream.
These hormones speed up heart rate, breathing
rate, blood pressure, and metabolism including
coping of growth in case of injury related damage.

132
Their net effect is to make a lot of stored energy,
glucose and fat available to cells. This provides
fuel for what has been traditionally referred to as
the ‘flight or fight’ response. Insulin is not always
able to let the extra energy into the cells, so glucose
piles up in the blood. Further gonodal hormones
are suppressed with a view that reproduction
should not occur in a living under stress (Dilman,
1989).
Physiological Changes
Blood vessels open wider to let more blood
flow to large muscle groups, putting our muscles
on alert. Pupils dilate to improve vision. The liver
releases some of its stored glucose to increase
the body’s energy. Sweat is produced to cool the
body (Kahn and Weir, 1996). All of these physical
changes prepare a person to react quickly and
effectively to handle the pressure of the moment.
Blood clotting mechanisms are more efficient with
a tilt towards pro-coagulation and tissue reactions
are towards damage recovery. The stress response
can cause problems when it overreacts or fails to
turn off and reset itself properly. People who are
experiencing stress overload may notice some of
the following signs (Wyngaarden et al., 1988):
· Anxiety or panic attacks
· A feeling of being constantly pressured,
hassled, and hurried
· Irritability and moodiness
· Sadness or depression
· Problems in sleeping
· Drinking too much, smoking, overeating, or
taking drugs
· Physical symptoms, such as stomach
problems, headaches, or even chest pain
· Allergic reactions, such as eczema or asthma
Such constant stress can also add to a variety
of other health concerns from ulcers to high
blood pressure
· It can also result in changes to emotions and
to the ways in which one behave that might
not be good for his diabetes
· Integrated electromyographic activity of the
temporalis muscle, but not the masseter
muscle, showed an increase that coincided
with the increase in sympathetic nervous
activity (Hidaka et al., 2004)
Stress Related Disorders
Stress can lead to disorders including
(Sudhalter, 2007):
· Headaches
· Viral infections
· Heart disease, high cholesterol and arterial
disorders
· Digestive disorders
· Asthma and allergies
· Cancer
· Adult-onset diabetes
· Memory impairment
According to the Occupational Stress
Research Institute, stress costs U.S. industry
some $150 billion a year.
The immediate effects of stress are usually
temporary and vary in severity from person to
person. But over time, they can damage heart,
arteries, brain, kidneys and eyes. Stress can
suppress immune system, making one more likely
to “catch” cold or contract more serious diseases.
Metabolic Strategy of Stressed Cell
Dynamic genetic and biochemical changes
make up a cell’s response to a shortage of
Coenzyme A (CoA), a key player in metabolism.
Coupled with genetic studies of the cell,
metabolomics is giving scientists a more detailed
picture of how the body maintains its health in
both normal environments and during times of
stress, such as starvation or disease. The
response observed to decreased CoA in a mouse
model by blocking CoA production with
hopantenate (HoPan) was studied. HoPan is a
chemical that interferes with pantothenate kinase
(PanK), the enzyme that triggers the first step of
CoA production. Following the shutdown of CoA
production, the cells quickly recycled CoA from
other sources, extracting life-supporting energy
from nutrients in the mitochondria. Low levels of
CoA trigger the activation of genes that block
other biochemical pathways that ordinarily use
this molecule. Instead, the cell shifts most of the
available CoA activity to producing glucose from
the liver. Other organs then break down glucose
into .pyruvate inside mitochondria. In the
mitochondria, CoA molecules feed pyruvate into
a complex series of chemical reactions that
produces molecules of ATP. Results identify the
re-arrangements that the cell’s metabolism
undergoes in order to ensure that the liver keeps
CoA levels high enough to produce glucose and
the cells of the body maintain enough free CoA
for the mitochondria to keep producing ATP (St.
Jude Children’s Research Hospital, Memphis:
Tennessee, 2007).
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133
STRESS AND DIABETES
There is no evidence that stress causes
diabetes. However, stress may sometimes unmask
diabetes, by causing blood glucose levels to rise
(Kahn and Weir, 1996). This is often seen after a
heart attack or stroke, where raised blood sugar
levels may be encountered for the first time. In
people who have diabetes, the fight-or-flight
response does not work well. Insulin is not always
able to let the extra energy into the cells, so glucose
piles up in the blood (ADA, 2007). Making things
worse, many sources of stress are not short-term
threats. For example, it can take many months to
recover from surgery. Stress hormones that are
designed to deal with short-term danger stay
turned on for a long time. As a result, long-term
stress can cause long-term high blood sugar
levels. Many long-term sources of stress are
mental. Like physical stress, mental stress can be
short term from taking a test to getting stuck in a
traffic jam. It can also be long term, from working
for a demanding boss to take care of an aging
parent. In mental stress, the body pumps out
hormones to no avail. Physical stress, such as
illness or injury, causes higher blood glucose
levels in people with either Type of diabetes.
Stress blocks the body from releasing insulin in
people with Type 2 diabetes. The diagnosis of
diabetes usually comes as a shock and is certainly
a stressful time (Wijenaike, 2002; ADA, 2007).
Changes in lifestyle including stoppage of
smocking, diet and learning to manage injections
may all contribute in addition to the worry
regarding chronic illness (Davis et al., 1999).
In people who have diabetes, stress can alter
blood sugar levels. It does this in two ways. First,
people under stress may not take good care of
themselves. People who are anxious are under
pressures and may lose appetite and skimp on
eating, or reach for not-so healthy quick fixes like
candy or chips and sometimes seek refuge in food
and drink. This can take the form of chocolates,
sweets and crisps, often in between meals. The
intake of alcohol may be increased. Many people
who are under stress turn to food as a source of
‘comfort’. This pattern of ‘comfort eating’ can
often play havoc with blood sugar level. Further
anxiety leads to less exercise. The results can be
disastrous for people with diabetes. They may
forget, or not have time, to check their sugar levels
or plan good meals. Second, stress hormones may
also alter blood sugar levels directly as it
antagonizes the action of insulin. While in most
people glucose levels go up with mental stress,
while in others can go down. Diabetic mice under
physical or mental stress have elevated glucose
levels. The effects in people with Type 1 diabetes
are more mixed. People with Type 1 diabetes may
develop elevated blood glucose levels and
ketoacidosis. Those with Type 2 diabetes usually
gain weight and develop obesity and often blood
sugar levels are raised (ADA, 2007). Inflamma-
tory signaling pathways can also become
activated by metabolic stresses originating from
inside the cell as well as by extra-cellular signaling
molecules. It has been demonstrated that obesity
overloads the functional capacity of the endo-
plasmic reticulum and that this endoplasmic
reticulum stress leads to the activation of infla-
mmatory signaling pathways and thus contributes
to insulin resistance. Additionally, increased
glucose metabolism can lead to a rise in mito-
chondrial production of reactive oxygen species.
Reactive oxygen species production is elevated
in obesity, which causes enhanced activation of
inflammatory pathways (Wellen and Hotamisligil,
2005).
Physical stress, such as illness or injury,
causes higher blood sugar levels in people with
either type of diabetes. For some people with
diabetes, controlling stress with relaxation
therapy seems to help. It is more likely to help
people with Type 2 diabetes than people with
Type 1 diabetes. Stress blocks the body from
releasing insulin in people with Type 2 diabetes,
so cutting stress may be more helpful for these
people. People with Type 1 diabetes do not make
insulin, so stress reduction does not have this
effect. Reducing stress can help people with Type
1 diabetes take better care of them. Some people
with Type 2 diabetes may also be more sensitive
to some of the stress hormones. Relaxing can help
by blunting this sensitivity. In people with Type
2 diabetes, mental stress often raises blood
glucose levels. It is easy to find out whether
mental stress affects glucose control. Many
glucose meters have the capability to enter
personal notes and data when one perform
checks, or jot it down in a stress journal (Wijenaike,
2002). Once one begins recording stress levels,
most people with diabetes figure out pretty
quickly what makes his blood sugar to go up.
People with diabetes should stay conscious of
eating well and exercising regularly. It’s a good
idea to check blood glucose levels more frequently
DIABETES AND STRESS: A REVIEW

134
when ill or under stress and to drink plenty of
fluids as so as not to get dehydrated. Something
else that affects peoples responses to stress
coping style. Coping style is how a person deals
with stress. People who use them tend to have
less blood sugar elevation in response to mental
stress (ADA, 2007).
Hyperglycemia induces the overproduction
of oxygen free radicals and consequently
increases the protein oxidation and lipid oxidation.
A significance difference in the mean plasma
concentration of total antioxidant status was
observed in diabetic patients. A statistically
significant higher values of protein carbonyl
groups and MDA as lipid peroxides were
observed in diabetic patients with slight reduction
in the synthesis of nitric oxide. It is interesting to
note that there was a decrease in the antioxidant
levels with corresponding increased protein and
lipid oxidation. Decreased levels of proteins -
albumin, transferrin, ceruloplasmin and hepto-
globulins and variable GC globulin fractions in
diabetes were found compared to normal healthy
controls (Vadde and Jailkhani, 2007).
DEALING WITH SUCCESS
The most helpful method of dealing with
stress is learning how to manage the stress that
comes along with any new challenge, good or
bad. Stress-management skills work best when
they’re used regularly, not just when the
pressure’s on. Knowing how to “de-stress” and
doing it when things are relatively calm can help
one get through challenging circumstances that
may arise. Here are some things that can help
keep one to keep stress under control (Strickland
et al., 2007; Wijenaike 2002; Heiden et al., 2007;
Meadows-Oliver et al., 2007)
· Regular courses of yoga, meditation or deep
breathing
· Progressive relaxation therapy in which one
practices tensing and relaxing major muscle
groups in sequence
· Cognitive behaviour therapy by helping one
to change his behaviour and teaching to view
the life through more appropriately colored
glasses-to take a stand against over-sche-
duling, be realistic, solving the little problems,
to watch what one is thinking
· Talking to a therapist
· Step back from the situation
· To keep up healthy eating and exercise routine
· To get a good night’s sleep
· To eliminate Caffeine
· Anti-anxiety medication
· To take up a relaxing hobby
· Replace bad thoughts with good ones
· Biofeedback training
· Massage
· Other ways to reduce mental stress- outlook,
attitude, and thoughts influence the way to
see things. A healthy dose of optimism can
help one to make the best of stressful circum-
stances.
· Building Resilience
· Thinking of change as a challenging and
normal part of life
· To see setbacks and problems as temporary
and solvable
· To believe that one will succeed if he keeps
working toward his goals
· To take action to solve problems that crop up
· To build strong relationships and keep
commitments to family and friends
· To have a support system and ask for help
· To participate regularly in activities for
relaxation and fun
· Tai Chi- Tai Chi chuan (Tai Chi) is an ancient,
widely practiced Chinese martial arts form. Like
yoga, it is designed to enhance both physical
and emotional well-being (Sudhalter, 2006).
· A sniff of lavender- Aromatherapy, which relies
on the use of essential volatile oils of flowers
and fruits to cause biochemical effects, has been
proven to have positive effects on the mood.
When it comes to stress, lavender is supposed
to be particularly uplifting (Sudhalter, 2006).
CONCLUSION
It’s hard to dispute that most of us live life at
breakneck speed. Stress is a feeling that’s created
when one reacts to particular events. It’s the
body’s way of rising to a challenge and preparing
to meet a tough situation with focus, strength,
stamina, and heightened alertness. The events
that provoke stress are called stressors, and they
cover a whole range of situations- physical, like
injury or illness. Or they can be mental, like
problems in marriage, job, health, or finances. The
body gears up to take action in response to stress.
This preparation is called the fight or flight
response. In the fight or flight response, levels of
many hormones like catecholamines, cortisol and
growth hormone shoot up. Their net effect is to
ANALAVA. MITRA

135
make a lot of stored energy, glucose and fat
available to cells. Insulin is not always able to let
the extra energy into the cells, so glucose piles
up in the blood. These results in increase
propensity of various diseases and diabetes may
be an outcome of stress, which further sets in a
vicious cycle of stress-diabetes relationship. The
most helpful method of dealing with stress is
learning how to manage the stress that comes
along with any new challenge, good or bad.
Stress-management skills work best when they’re
used regularly, not just when the pressure’s on.
Knowing how to “de-stress” and doing it when
things are relatively calm can help one get through
challenging circumstances that may arise.
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DIABETES AND STRESS: A REVIEW