August 2018 Issue

Diabetes Management & Nutrition Guide: Mind-Body Exercises and Therapies
By Jennifer Van Pelt, MA
Today's Dietitian
Vol. 20, No. 8, P. 50

Mindfulness-based activities can help those with diabetes cope with the stress of their chronic condition.

Due to the potential for serious side effects if diabetes isn't managed properly, most clients with diabetes will understandably focus on their medications, diet, and blood glucose measurements. Depending on the type and severity of their disease, daily management may be quite rigorous and require diligence, especially with busy work and family schedules. Having to manage diabetes all day every day takes a heavy toll; many patients with diabetes experience emotional and mental distress, mental fatigue, and "burnout" from the daily stresses of diabetes management. Diabetes distress is now a recognized diagnosis, defined as "significant emotional reactions to the diagnosis, threat of complications, self-management demands, or unsupportive social structures" associated with living with diabetes; in many cases, diabetes distress causes a substantial emotional and mental burden. Feelings associated with diabetes distress may run the gamut from anger and denial to frustration and loneliness. Almost every aspect of diabetes care requires balancing medical care with one's personal life—24 hours a day, seven days a week. The intensity of these self-management efforts can overwhelm patients with diabetes very quickly. Diabetes distress is estimated to occur in about one-half of those with type 1 or type 2 diabetes.1

Common emotional stressors that can lead to diabetes distress include the following:

  • remembering to take medications at the right time every day;
  • worrying about hypoglycemia;
  • affording the recent tremendous increase in the cost of insulin;
  • fearing the development of serious diabetes-related complications, such as blindness, kidney damage, and foot ulcers leading to amputation;
  • feeling self-conscious about having to test blood glucose around others;
  • maintaining a healthful diet appropriate for diabetes management, especially when family members don't follow the same diet and in social situations centered around food;
  • feeling alone and isolated while living with diabetes; and
  • feeling guilty when diabetes management doesn't go well.

Diabetes distress has been linked to poor adherence to treatment regimens, poor glycemic control, higher rates of complications, and decreased quality of life.1,2

Stress associated with diabetes management can adversely impact glycemic control, leading to rapid and possibly substantial increases in blood glucose levels. These increases may be due to physiologic responses to stress, missing medications due to diabetes distress, or a combination of the two. Stress also leads to negative thinking and emotions, impairs decision making, and causes physical and mental wear and tear. Consistently high levels of stress can lead to anxiety and/or depression; clients with diabetes are at higher risk of developing one or both of these conditions than those without diabetes. Anxiety and depression are underdiagnosed and undertreated in patients with diabetes.3,4

Rates of depression among individuals with type 1 diabetes are three times greater than the general population and two times greater for those with type 2 diabetes.1 Research has shown that depression affects one's ability to manage diabetes and may lead to behaviors that worsen the disease, such as smoking, eating poorly, sleeping less, and not exercising. The occurrence of depression in those with diabetes is separate and distinct from diabetes distress; approximately 70% of individuals with diabetes distress don't meet diagnostic criteria for depression. But the conditions can occur together, and diabetes distress frequently can lead to depression and/or anxiety.1-4

How to Help Clients
The American Diabetes Association recommends that all patients with diabetes be routinely screened for psychosocial problems, such as diabetes distress, depression, and anxiety. However, such screening often isn't performed during medical appointments, and mental/behavioral health services aren't yet well integrated into diabetes clinical care. Clients with diabetes can be encouraged to ask their physicians about mental health screening.

To help individuals with diabetes manage stress, mind-body techniques have been recommended for about 15 years; however, uptake has been slow. Given the overall growing interest and participation in mind-body exercise, meditation, and mindfulness-based stress reduction practices, their application for those with diabetes also is increasing and becoming an integral part of diabetes management. Clients already may be practicing yoga, tai chi, or qigong as part of their exercise program, all of which have mind-body and meditative aspects that help with relaxation and stress management. If your clients with diabetes haven't yet added one of these activities to their weekly exercise regimen, suggest they do, as all three have been shown to provide benefits to those with diabetes.

An April 2018 systematic review found that both tai chi and qigong were effective in reducing fasting blood glucose and BMI in those with diabetes. Tai chi also was found to improve quality of life, while qigong also was found to improve glycosylated hemoglobin and reduce depression.5 A 2016 systematic review found that practicing yoga can lower oxidative stress and blood pressure and improve mood, sleep, quality of life, glycemic control, and lipid levels in type 2 diabetes.6 Several other studies have found similar diabetes-related benefits associated with yoga. Clients don't need to do vigorous yoga—gentle, slow, and restorative yoga all provide benefits.

Adding a mind-body component to diabetes management doesn't have to involve exercise—benefits can be realized with just a few minutes of relaxation breathing or mindful meditation each day or mindfulness-based therapies. A 2017 systematic review found that mindfulness-based interventions (none involving exercise) reduced distress, depression, and anxiety in those with diabetes.7 A small 2018 study found that a mindfulness-based stress reduction program significantly improved diabetes distress, psychological self-efficacy, depression, anxiety, coping, and self-compassion in patients with diabetes.8

Clients can find mindfulness-based stress reduction programs in their local communities in a range of locations, including community centers and yoga studios, and education and medical facilities. Programs also are available as online courses. For busy clients who prefer not to invest much time or money initially, there are many smartphone and computer apps geared toward daily mindful meditation and stress relief, such as The Mindfulness App, Headspace, Calm, Breathe2Relax, and Stop, Breathe & Think. Some are free, while others offer a free trial and subsequent minimal monthly fees. Mood trackers also are available if clients are interested in tracking the frequency of diabetes-related stress and its impact on their mood. For clients who already are using diabetes apps for tracking and reminders for medication and diet, adding an app for stress management and/or meditation should be relatively easy. Most meditation/relaxation apps have features that enable the user to choose music, time spent, and visual/audio instructions. Just five to 10 minutes of simple relaxation breathing daily, guided by an app, can help reduce stress.

Research on the use of mobile apps for management of diseases, including diabetes, has shown benefits in terms of symptom control and adherence to treatment regimens. Research on general stress reduction from mindful meditation and relaxation apps has shown benefits. However, research on the use of apps specifically for reducing stress associated with chronic disease management is limited. One small study published in 2017 evaluated the use of a mobile app for biofeedback-assisted relaxation on weight, blood pressure, and glycemic measures in seven patients with type 2 diabetes. The researchers found that the app improved glycemic control, weight, and blood pressure, indicating that reducing stress can positively influence disease management.9

Technology and research have brought mindfulness practices and their benefits into the mainstream. In the past, patients with diabetes may have been told to just "deal with" the daily stress of diabetes management. Now, several options for alleviating diabetes distress are easily accessible for clients and patients.

— Jennifer Van Pelt, MA, is a certified group fitness instructor and health care researcher in the Lancaster, Pennsylvania, area.

1. Kreider KE. Diabetes distress or major depressive disorder? A practical approach to diagnosing and treating psychological comorbidities of diabetes. Diabetes Ther. 2017;8(1):1-7.

2. Ducat L, Philipson LH, Anderson BJ. The mental health comorbidities of diabetes. JAMA. 2014;312(7):691-692.

3. American Diabetes Association. Standards of medical care in diabetes — 2016. Diabetes Care. 2016;39(Suppl 1):S1-S112.

4. Lloyd C, Smith J, Weinger K. Stress and diabetes: a review of the links. Diabetes Spectrum. 2005;18(2):121-127.

5. Yu X, Chau JPC, Huo L. The effectiveness of traditional Chinese medicine-based lifestyle interventions on biomedical, psychosocial, and behavioral outcomes in individuals with type 2 diabetes: a systematic review with meta-analysis. Int J Nurs Stud. 2018;80:165-180.

6. Innes KE, Selfe TK. Yoga for adults with type 2 diabetes: a systematic review of controlled trials. J Diabetes Res. 2016;2016:6979370.

7. Noordali F, Cumming J, Thompson JL. Effectiveness of mindfulness-based interventions on physiological and psychological complications in adults with diabetes: a systematic review. J Health Psychol. 2017;22(8):965-983.

8. Whitebird RR, Kreitzer MJ, Vazquez-Benitez G, Enstad CJ. Reducing diabetes distress and improving self-management with mindfulness. Soc Work Health Care. 2018;57(1):48-65.

9. Munster-Segev M, Fuerst O, Kaplan SA, Cahn A. Incorporation of a stress reducing mobile app in the care of patients with type 2 diabetes: a prospective study. JMIR Mhealth Uhealth. 2017;5(5):e75.