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Diabetes Stress: 2 Ways to Feel More in Control

For those with diabetes, there are two equally effective approaches that can help ease the anxiety that often arises. Choose the method that works best for you: be it emotion-based or knowledge-based to help you cope better.

With Lawrence Fisher, PhD, and Kimberly Driscoll, PhD

As is common with chronic diseases, managing diabetes, in particular, type 1 diabetes, can be very stressful, with up to half of those with diabetes reporting that they are feeling stressed and mentally exhausted.1

If you've experienced these emotional lows, you don't need a definition; you know that having diabetes mellitus can be overwhelming as you try to cope with the day-in, day-out adjustments needed to control your diabetes.

Two new programs help people with diabetes cope better and worry less.Learning emotional strategies to reduce anxiety, and tips to manage their diabetes better leads to less stress and better health. Photo: 123rf

And yes—It's a lot to handle—checking your blood sugar, remembering to take your medications, or making sure your glucose device is working properly. Then, there’s the added challenge of getting in some physical activity, and, of course, making the right food choices. Is it bedtime yet?!

In the end, each of these tasks is manageable but all together, diabetes care is more than just worry; it can be intertwined with depression, anxiety, and stress, at any one time, says Lawrence Fisher, PhD, professor emeritus at the Diabetes Center at the University of California in San Francisco (UCSF).

But you can feel better—and do better.3 Dr. Fisher led the T1-REDEEM study, in which his team compared two different approaches he is developing to address the stress of having type 1 diabetes—one emotion-based and the other knowledge-based. Both methods helped reduce the distress that comes with diabetes. Better still, by reducing the stress, individuals with diabetes also had modest improvements in their hemoglobin A1c levels.3 The study findings appeared in Diabetes Care, the professional journal of the American Diabetes Association.

Two Ways to Lessen the Emotional Distress that Comes with Having Diabetes

Dr. Fisher randomly assigned 301 men and women with type 1 diabetes to one of two programs:3

  • OnTrack— the program focuses on emotional strategies
  • KnowIt—is the education-based program.

Both programs require the same time commitment from participants including attendance at a one-day group workshop guided by a specially trained group leader. For example, a certified diabetes educator led the KnowIt group, and a psychologist with experience in helping people with diabetes ran the For OnTrack group.

The participants also participated in four one-hour online video meetings with the leader and the other group members over the course of the next three months. The researchers conducted a follow-up assessment through an online survey. In addition, A1c levels were tested twice after the initial workshop: at three months and again at nine months.3

The men and women who were part of the TI-REDEEM study were, on average, in their 40s. They had been diagnosed with type 1 diabetes for about 23 to 26 years. Some participants were using an insulin pump, while others had a continuous glucose monitoring device.

In the KnowIt group, these participants were given tips such as easier ways to achieve carb counting. Their leader offered a toolbox of strategies to help each individual address specific blood sugar issues and to learn better ways to manage their diabetes care.

For those in the OnTrack program, participants were given a variety of scenarios that focused on how to deal with the emotional side of diabetes and how to develop techniques to get ''unstuck'' so they could experience positive behavior changes.

Different Strokes: Both Methods of Diabetes Self-Care Proved Effective

Individuals in both study groups were able to achieve a reduction in distress that was noticeable, Dr. Fisher tells EndocrineWeb. There were no significant differences seen in the amount of stress reduction that occurred between the individuals in either group.3 However, the researchers did find that one program helped more than the other, depending on the person.

For instance, the KnowIt approach was a better choice for people who came in with less than ideal information about diabetes management; the individuals who needed a good primer on the basics of type 1 diabetes responded best to this program, says Dr. Fischer, whereas the OnTrack approach appeared most effective for those individuals who arrived with a very high level of stress and a reasonable level of knowledge about managing their diabetes but who needed to gain control over the emotional side of their life.

“These are the people who tend to blame themselves when their diabetes is not managed well,” he says. For anyone who is facing anxiety, stress, or depression, "basically what we do is to label, identify, and discuss what the group members are experiencing emotionally around their diabetes. By presenting a variety of scenarios," Dr. Fisher says, " it gives each person the room to work out their own struggles.”

T1-REDEEM Simultaneously Lessened Stress AND Improved Blood Glucose 

Dr. Fisher and his research team found that in achieving a reduction in stress, the participants also experienced a slight drop in their A1c levels.3 For instance, at the beginning of the study, the overall mean for A1c was 8.8%. By the end of the study, at nine months with no change in their medications, the average A1c level dropped to 8.62—8.59% in the KnowIt group and to 8.65% in patients in the OnTrack group.3

These reductions in average blood sugar levels were significant from a statistics point of view, even if there wasn’t a huge drop, says Dr. Fisher. Previous studies have found similar results so we need to study this slight improvement in blood glucose to gain a clearer understanding of the reasons why the A1c doesn't drop more as the level of distress declines.4

Having Two Methods to Reduce Stress is Good for Patients with T1D

Another expert, Kimberly Driscoll, PhD, associate professor of pediatrics at the University of Colorado in Denver, calls the findings ''very encouraging" even though the research did not find any between-group differences for which approach might yield better stress reduction in patients with type 1 diabetes.

Dr. Driscoll, who reviewed the findings for EndocrineWeb but was not involved in the study, suggests that individuals may want to consider a combination of both approaches. Getting some education and some coping strategies might be even better.

"I look forward to seeing future studies that combine the KnowIT and OnTrack interventions because I think the synergy of the two could be really powerful for people with type 1 diabetes," she says. So many people need help in managing both the medical and emotional aspects of their diabetes, says Dr. Driscoll.

With her own patients, Dr. Driscoll supports the idea that they get help to address the struggles in trying to deal with their diabetes care.

As to reason that these stress-reducing programs did not lead to a greater drop in A1c, she says, “there is not a simple answer.” We know from other studies that no overwhelming changes in A1c occur even as the level of stress goes down dramatically.4,5

"Most of the past studies only show about a 0.5% reduction in A1c," she says. She notes that it is difficult to change A1c levels even when someone with type 1 diabetes does the same activities and eats the same food on two consecutive days since their blood glucose values can vary.

Getting Support to Cope Better and Improve Self-Care Is Very Important

According to Dr. Driscoll, getting help in dealing with negative emotions by talking to someone who has sound training in and an understanding of what it takes to manage diabetes is essential. ''Unfortunately, there is a shortage of therapists who specialize in type 1 diabetes," a fact that her patients talk about often, she says.

Dr. Fisher agrees—more mental health support is needed to help individuals learn to cope better, reducing their diabetes distress. As such, he says he will continue to study these approaches.

Meanwhile, Dr. Driscoll points to another program that may also help many patients. "The American Diabetes Association (ADA) and the American Psychological Association (APA) have partnered to increase the number of psychologists who can treat people with type 1 diabetes by providing combined in-person and online workshops prior to each association's annual conference, which I think is a significant contribution to the field."

To find a qualified therapist, you can access the directory of professionals who have completed the ADA/APA training program here.   

The study, called T1-REDEEM, for Reducing Distress and Enhancing Effective Management for adults with type 1 diabetes, was supported by the National Institute of Diabetes and Digestive and Kidney Diseases.

Neither Dr. Fisher or Dr. Driscoll have any financial disclosures.

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