Living with Diabetes: Psychological Challenges

WebMD Live Events Transcript

A chronic condition like diabetes can have a profound effect on the mind. Did you know depression is three times more common among people with diabetes than the general population? We'll discuss the emotional side of this physical condition with S. Sethu K. Reddy, MD, director of the Department of Endocrinology, Diabetes, and Metabolism at the Cleveland Clinic.

Support for this University course was provided by Medical Mutual.

MODERATOR:
Welcome to WebMD University: "Diabetes: Get the Advantage." Your instructor today is Sethu Reddy, MD, FACE, director of the department of endocrinology, diabetes, and metabolism at The Cleveland Clinic. He joins us for a look at the psychological side of living with diabetes.

Dr. Reddy, can your emotions raise your blood sugar?

REDDY:
Yes, emotional stress can raise blood sugar and also cholesterol levels. Stress can raise adrenalin levels hugely, and adrenalin can raise your blood sugar, sometimes as much as 10 to 30 milligrams percent. Some of our patients note that when their sugars are higher they tend to be more tired and frustrated and maybe prone to feeling more stress than usual.

MEMBER QUESTION:
My blood sugar yo-yos up and down regardless of what I eat or when. How can I cope with that?

REDDY:
A good question. I think we need to remember that sugars do fluctuate. One misconception people have, when they are put on medication or some regimen, is that their sugar levels will be flat.

In reality, whenever we eat food, normally our sugar can go up to as high as 199 one hour after eating and come down below 140 two hours after eating. These kind of fluctuations are considered normal. Also, exercise can have different effects on blood sugar. If you have type 2 diabetes, which 85% of people with diabetes have in the U.S., exercise typically improves blood sugar levels.

On the other hand, if someone performs extremely strenuous exercise, one can elevate the adrenalin and other hormones so high that sugars can actually become elevated. This is not a problem for most of our patients.

For individuals who may have type 1 diabetes and are taking insulin injections for therapy, they are much more likely to have wider swings of blood sugar. If they exercise and don't have much insulin on board, then their sugars can go very high, and if they have lots of insulin on board and exercise strenuously without enough food, they can have severe low blood sugar reactions. Typically, exercise does not improve the overall control in individuals with type 1; however, exercise is very important for lowering risk of heart disease, raising your good cholesterol, and psychology of well-being.

MEMBER QUESTION:
I have been recently diagnosed as type 2 and seem to be in denial. What can I do to get past this stage?

REDDY:
This is a very common. It's important to have a family member or a tolerant physician you can discuss these thoughts with, and certainly recognizing that one is in denial is the first step to improvement.

In the old days, we used to think of hypertension as a silent killer, but now diabetes should also be considered a silent killer -- most of us have no symptoms when our sugars rise to high levels. Many of us think we don't have diabetes until we're put on insulin therapy. But in reality, despite having no symptoms, high sugar levels continue to damage:

• Eyes

• Kidneys

• Heart

• Nerves

I think the first step is to be more educated about the future ramifications of high blood sugars and to think about the management, like you would in getting a life insurance policy.

Remember that life insurance premiums at age 30 are very low, but at 65 are very high. Very early in the state of diabetes, very minor diet and lifestyle modifications can have tremendous benefits. We are getting safer and more tolerable treatments each year; for example, inhaled insulin is also around the corner. Artificial pancreases will also be the new state of technology in five to 10 years. All these advances allow a person to lead a fairly normal life.

Remember, we don't expect individuals to follow many of the dietary and lifestyle principles 100% of the time. We would be very happy if people followed them 85% to 90% of the time. I often tell my patients that if they're very compliant with their lifestyle changes, perhaps once a month or once every few weeks they can reward themselves with a more pleasing lifestyle experience with respect to diet or exercise.

It is sad, sometimes, when we see individuals that do not seek medical attention until they start losing vision or start losing sensation in their feet. So we see the denial quite often, but it's an ongoing challenge.

MODERATOR:
What is a good source of access to cutting-edge treatment information so we can be more hopeful about the future?

REDDY:
One can visit:

• WebMD

• www.diabetes.org (from the American Diabetes Association), which gives the latest on research and advances

• www.nih.gov (National Institutes of Health) to look up diabetes in some of the latest government-sponsored trials

Two more sources one can use to catch up:

• One should get involved in local diabetes health fairs, where you can actually go and firsthand ask questions about advances or see some of the latest technology.

• The American Diabetes Association has an annual scientific meeting each June, where many people with diabetes attend and are particularly welcome. There may be several hundred exhibitors from various industries, as well as excellent seminars about the latest advances.

MEMBER QUESTION:
Can you talk about the emotional impact of not having an end in sight with this disease? It's not a broken leg or the flu, it's permanent, and that's a heavy load to bear!

REDDY:
It's a very important question. One worries about so-called burnout in our patients. It is a lifelong condition and requires daily monitoring. Certainly for children with diabetes this can become an enormous burden.

In fact, what some parents do for children, perhaps every two to three months, they give the child a holiday from the day-to-day monitoring and treatment. The parents could check the blood sugar and do the injections, take over the mental work related to the diabetes. This way the child gets a break.

For our adults, there's a theme in psychology that if one performs a task 17 times, that it can become a habit. I tell my patients that a person with diabetes can do anything someone else can do, but they have to plan ahead.

If a person is planning a ski trip, then they know to check their blood sugar during the middle of their exercise and so can enjoy the skiing without any incident. If someone is going out for an anniversary dinner, they can adjust their insulin prior to the meal so that they can accommodate the extra calories.

This way they are actually enjoying everyday activities the nondiabetics are enjoying, and one does not have to feel restrained. In the future, with an implantable glucose sensor connected to an insulin pump becoming available, one can envision total freedom, and it would be unnecessary to feel the stress of day-to-day and minute-to-minute supervision of activity and medications.

A key step to reducing the stress in today's climate would be to make some of these activities, like sugar monitoring and insulin administration, as routine and scheduled as possible. That way, one gets into -- like brushing one's teeth in the morning -- it becomes a habit and is not seen as an intrusion. Glucose monitoring, now, can take only 20 to 30 seconds, and insulin administration can be performed with a pen device, allowing patients to check their blood sugar quickly and anywhere and also conveniently take their insulin.

MEMBER QUESTION:
I was diagnosed with diabetes a year ago. I was very active, and now I don't have the energy to do anything. I feel weak because of my disability and sometimes I feel like just giving up and letting it have its course. I have no one to talk to about this.

REDDY:
This brings up a very important point. Just the fact of telling someone they have type 2 diabetes changes their body image and perception of their health. Many of our patients with type 2 diabetes are, in fact, healthier than nondiabetics. They exercise regularly, eat properly, control their blood pressure and cholesterol, and are successful members of their family and society. We'd like to think of diabetes as a yellow flag and force us to perhaps re-evaluate our lifestyle and improve upon it.

Also, we need to look for other causes for the reduced energy. A few possible causes:

• High sugar levels can cause low energy

• Depression is said to be two to three times more common in people with type 2 diabetes

• Some medications used to treat high blood pressure can cause reduced energy

• An underactive thyroid may also cause less energy

It's very important to look for other causes for the fatigue and potentially bring the energy level back. Too often, people contribute tiredness to middle age or getting older, but often there is a correctable cause.

It's important not to let the diagnosis stigmatize your entire life, but rather it should be a stimulus to maintain your health and also incorporate healthy habits for your family.

MEMBER QUESTION:
My husband and elderly mother believe diabetes is not a serious disease. How can I educate them?

REDDY:
This happens sometimes when the individual with diabetes wants to improve their health but their spouse keeps bringing the wrong foods home or always pushing more food on to their plates in a loving, family way. But one has to be firm and tactfully refuse some of these kindly gestures.

It would also be helpful to have your husband or mother accompany you to a doctor's visit; sometimes it's better for them to hear it from the doctor rather than from you. This way, the visit serves as an educational tool and will stress the importance of diabetes control.

Try to involve your family members in your exercise activity and on visits to the drugstore or local health fairs. This has to be done gently, since sometimes the fear of complications affecting their loved one will cause even more stress.

I think you could also encourage your family members that it takes a lot of teamwork to succeed with your diabetes management and any help they can give would be welcome, and like the prayer says, "lead us not into temptation." It would help if they did not tempt you with the wrong foods or denied you access to exercise.

MEMBER COMMENT:
When I was diagnosed in March, the doctor had me attend a diabetes education class. In the class was an older gentleman with diabetes who had also brought his wife. She was there for support and also to learn more about diabetes, so she could better help her husband. When I got home from the class, I shared what I knew with everyone in the house, including the 7-year-old. Now, he even asks how I am testing!

REDDY:
That's a great comment and proves how important diabetes education is for the whole family, rather than just the individual. We mustn't forget that type 2 diabetes is hereditary and can affect up to 50% of the children. So the awareness of diabetes and related lifestyle changes by the 7-year-old is fantastic.

MEMBER QUESTION:
What should I do about the sweets cravings (chocolate!) I get now and then?

REDDY:
It's always interesting that when one is told not to eat something, typically the cravings for that item increases. You should remember that if your sugar levels are too low due to medication or insulin, you will be hungry and craving sweets.

With respect to chocolate, if it's a once-a-month or an occasional craving, then it should not be a big problem. There are several low-carb, low-sugar chocolates available, or you could improvise and add chocolate to soy milk. That might be a healthier alternative. A word of caution: Chocolate itself may not be bad, and many nutritionists have claimed some benefits to chocolate, but chocolate often comes with a high fat component, and these other elements may be harmful to your long-term health.

In terms of sweets, juices tend to have almost as much sugar as soft drinks, so we tend to advise patients to cut back on the amount of juice intake. Whole fruit might a better alternative.

An important way to reduce the carbohydrate intake is to visualize how you would say no to such a food item. If you're attending a social function and someone offers you cheesecake or a rich tart, you would have already rehearsed a polite "no, thank you," and choose a healthier snack. This technique has been used by many professional athletes and other successful people in other situations and has found to be very effective.

So with Thanksgiving coming up soon, you may want to rehearse some healthy responses to your host!

MEMBER QUESTION:
I want to lose 40 pounds I gained because of antidepressant medication, but I find it hard because I am anxious about my sugar going low, but if I exercise after eating, I am too heavy to exercise -- what can I do?

REDDY:
This comment raises an issue of relationship of antidepressants to weight gain. Our experience has been that some individuals respond to certain antidepressants with significant weight gain despite no change in diet or exercise.

One strategy would be to change to another antidepressant and to embark on a formal weight loss program. We have been successful with weight loss in these situations, and thus we know this is a not a permanent problem. I cannot say that one particular antidepressant causes weight gain, and I have seen a variable response in different individuals. We often tend to switch patients to a medication like Celexa or Lexapro or Wellbutrin, which may reduce some cravings and are not associated with as much weight gain.

The other important point is how to break the vicious cycle of gaining weight, not being able to exercise and gaining further weight. If a person has a significant weight problem, we would suggest a medically supervised weight loss program to initially reduce the weight by 20 to 30 pounds, and at that point to encourage an exercise program and proper diet to either maintain or continue a more moderate rate of weight loss.

As you're losing weight, if you find your sugars are going too low, you definitely need to reduce your diabetes medication at the same time. If you're not on any medications, your sugar should not go too low.

MEMBER QUESTION:
What "rehearsed line" can I come up with to answer those around me that are too "helpful" -- Did you test your sugar? What was it? Should you be eating that?

REDDY:
That's a tough question. If you are actually eating a healthy item, then it's very easy to protect yourself. If it's not a healthy item, but your assessment is that over the course of the day you're eating a balanced, healthy diet, and this should not be a problem long term -- this might be an explanation.

You can remind your friend that the American Diabetes Association does allow up to 15% of your total daily calories from simple sugars. So remember that your overall diet should be low in fat, high in fiber, and balanced across the day.

MODERATOR:
Dr. Reddy, do you have any final words of wisdom for us?

REDDY:
Remember that diabetes is a condition and stays with us wherever we go. Sometimes it's important to make our lifestyle changes habits so that it doesn't seem like an onerous chore. How we deal with diabetes psychologically will make it greatly easier for our families and probably will improve our long-term success with treatment regimens and preventing complications.

MODERATOR:
Thanks to Sethu Reddy, MD, FACE, director of the department of endocrinology, diabetes, and metabolism at The Cleveland Clinic, for sharing his expertise with us today.

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