The clinical challenge
Overlooked contributors to elevation of glucose levels are mental health issues: anxiety, depression, and “stress.” The association between anxiety, depression and diabetes is well understood; either or both conditions can lead to poor self-care, eating poorly, being sedentary, and increasing weight. Inversely, poor self-care related to living with anxiety and depression may contribute to the development of type 2 diabetes. This has long been identified, but we often struggle to work with people with diabetes to find solutions, as resources are few and the expertise of the healthcare professional is often limited. Finding ways to manage anxiety and treat depression may improve glycemic control.
Stress, whether it be emotional or physical, is often overlooked as a cause of hyperglycemia – both short term and long term. The stress of managing diabetes, trying to achieve glycemic targets without success for example, can contribute to hyperglycemia. Other sources of stress, mental or physical, lead to hyperglycemia.
The mechanism is quite simple: stress causes the “fight or flight” response, increasing counter regulatory hormone production, glucagon, cortisol, growth hormone, and epinephrine, causing an increase in both glucose production and insulin resistance. When attempting to identify the cause of hyperglycemia and identify management changes, unlike the typical contributors – too much carbohydrate, not enough exercise, inconsistent medication-taking or disease progression – stress is less often thought of as the reason for unexplained hyperglycemia.
A pragmatic solution
It would be virtually impossible to eliminate stress as a contributor to hyperglycemia; however, raising awareness regarding stress-related hyperglycemia may help people living with diabetes as well as the diabetes care team to more effectively troubleshoot and strategize methods to reduce glucose levels. Typical approaches do not often address life stressors or mental health issues the person with diabetes may be experiencing. Adding a simple question to your interview to assess for stress as a contributor to hyperglycemia may help to identify when individuals are struggling with stress or other mental health issues that may be the root cause of poor glucose control. Manipulation of diet, exercise, or medication will have little success in these cases, in fact this may potentially increase diabetes burden.
Become more comfortable with talking about stress as a contributor to hyperglycemia. Assess for it and acknowledge it.
Discuss stress reduction strategies, such as mindfulness, exercise, improved sleep, and accessing support systems, while reinforcing healthy lifestyle interventions and medication adherence. It is important to consider all contributors to hyperglycemia, and stress is often overlooked.
About the contributor