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Gastroparesis

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Diabetic Neuropathy

What is Diabetic Neuropathy?
Neuropathy Affecting The Feet
Advice on Cutting Your Toenails
Symptoms of Neuropathy Affecting Your Feet and Hands
Heel Fissures
Charcot Foot
Wrong Sized Shoes
Neuropathy and Antidepressants
Diabetic Holiday Foot Syndrome
Patient and Family Carer Experience
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Gastroparesis

 

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Gastroparesis

Gastroparesis is a stomach condition estimated to affect 25% of people with diabetes to a greater or lesser extent. It is caused by neuropathy affecting the nerves of the stomach so that the stomach muscles do not work properly and the food remains in the digestive system for a longer time than normal. The symptoms include:

  • nausea
  • vomiting
  • abdominal bloating, discomfort and/or pain
  • feeling full soon after eating
  • indigestion or heartburn

In addition, as the food remains in the stomach for a longer time, gastroparesis affects blood glucose control which can result in erratic blood sugars.

New development
In the US a company, Medtronic, Inc, has developed an implantable device that has been shown to improve the symptoms of gastroparesis. The device delivers mild electrical pulses to the nerves in the stomach which stimulate digestion. A study involving 100 patients from various countries, showed that there was a variety of responses to the device but 93% of the participants vomited less than half as many times after using the device and most of them felt better after using the device. This treatment is called Enterra therapy and has been available in the US since March 2000.

Diabetes and Coeliac Disease

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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What is Coeliac Disease?

  • It is a condition in which the lining of the small intestine is damaged by gluten. Gluten is a protein found in rye, wheat, barley and possible oats.
  • This damage prevents foods from being absorbed properly by the small intestine and so before diagnosis there is weight loss and possibly malnutrition.
  • Treatment is a gluten free diet.
  • It is prevalent in the UK although estimates of incidence vary from 1 in 1000 to 1 in 300 people.
  • It can be diagnosed at any age but mostly it is finally diagnosed in adulthood usually in the 30-45 age group.
  • Many other cases may remain undiagnosed or may be falsely diagnosed as irritable bowel syndrome and only a third of cases are ever diagnosed as coeliac disease and treated with a gluten free diet.
  • Certain groups are at greater risk of developing coeliac disease – people with Type 1 diabetes, Downs syndrome, thyroid disease and osteoporosis.

Research in Finland looked at 300 people with coeliac disease and showed that:

  • Only 24% of 300 people with coeliac disease had classic symptoms,
  • 36% had minor symptoms,
  • 27% were diagnosed with associated diseases and 13% by chance.
  • 51% had another autoimmune disease with 16% of this group having diabetes.

The Symptoms of Coeliac Disease

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
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Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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The Symptoms of Coeliac Disease

Coeliac disease can cause people to be acutely and severely ill with weight loss, vomiting and diarrhoea or symptoms may be chronic and seem unimportant, such as tiredness, lethargy and breathlessness but usually the symptoms are somewhere between the two. However, some people are diagnosed without having any symptoms.

Adults may have a history of abdominal discomfort or they may develop coeliac disease at any time. Anaemia, mouth ulcers and weight loss are common signs.

Babies are fit and well until the introduction solid foods that contain gluten when the baby would become pale, bulky, offensive-smelling stools and be lethargic and miserable.

All these symptoms could apply to other conditions, so it is important that you do not assume that you have coeliac disease but seek medical help.

Diagnosis

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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Diagnosis

Coeliac disease is nearly always diagnosed by a gastroenterologist. Until recently coeliac disease could only be detected after years of symptoms by an intestinal biopsy. The new test measures antibodies in the blood to gluten and gliaden in the diet and damaged endomysial muscle in the bowel. The anti-gliaden antibodies disappear with a gluten free diet but the endomysial antibodies persist in all people with untreated and treated coeliac disease and so it is an excellent screening test, although not 100% accurate.

Diabetes and Coeliac Disease

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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Diabetes and Coeliac Disease

Both diabetes and coeliac disease are autoimmune diseases and there are increasing amounts of research to show that there is a link between the two both in adults, children and adolescents. Increasingly there are views that more attention should be given to this link and that tests for coeliac disease should be routinely carried out in both adults and children with diabetes [ref 1].

Coeliac disease maybe the cause of vague abdominal symptoms and may cause hypoglycaemia due to impaired carbohydrate absorption in the gut.

A further study carried out in Oxford [ref 1] looked at 167 children and young people with diabetes. Antibody tests for coeliac disease were carried out and eleven [6.6%] were antibody positive and of the eleven:

  • only 1 had coeliac disease symptoms
  • 4 had a history of gastro-intestinal problems but not severe enough to seek medical advice
  • 6 showed no symptoms at all.

Nine of this group of eleven agreed to a biopsy and 8 of them had typical coeliac features of the small bowel. All were treated with a gluten-free diet and monitored for up to 2 years. They were symptom free. Those showing no symptoms at all before the study reported no change in their well-being and follow up biopsies showed normal appearances of the small bowel suggesting that treatment had been effective.

The authors point out that screening for coeliac disease in these youngsters with diabetes showed a high percentage had coeliac disease but the majority of them did not show the classic symptoms. At present it is not known whether treating symptomless people will be of benefit considering the riggers of the voeliac diet and whether or not they are at greater or lesser risk of the long-term complications of coeliac disease.
Ref 1 Coeliac Disease in Children and Adolescents with IDDM. D.B.Dunger et al. Diab Med, Vol 15: 38-44

Treatment – Diet For People With Coeliac Disease and Diabetes

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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Treatment – Diet For People With Coeliac Disease and Diabetes

A strict gluten free diet is the only treatment that puts the intestine back to normal.

Diabetes requires a well balanced diet with plenty of carbohydrate but once coeliac disease has been diagnosed, providing carbohydrate becomes more difficult as many of the carbohydrates we eat and enjoy, such as bread, pasta, cereal, pastry, crackers, biscuits and cakes contain gluten which has to be avoided. This is particularly difficult for children. These foods can be replaced with gluten-free products, some of which are available on the NHS in the UK. But as there is no gluten in the flour, the products do not have the same consistency and taste and are often not so delicious.

Here are just some of the difficulties:

  • There is a lack of choice
  • Pre-prepared foods are much more difficult to obtain because many of them contain gluten eg the flour used to thicken sauces contains gluten.
  • It takes time to become familiar with the ‘hidden’ gluten eg wheat flour is often used as a carrier for flavouring in such things as crisps.
  • Buying gluten-free products is very expensive.

The Experiences of a Family Living With Diabetes and Coeliac Disease

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
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The Experiences of a Family Living With Diabetes and Coeliac Disease

As a family we have learnt to cope with coeliac disease and diabetes, but it is not easy. As we know, children hate being different and believe it or not some find living with coeliac disease more difficult than living with diabetes. Coeliac disease makes a child more obviously different from their friends and family and it can bring emotional and behavioural problems that can be difficult to deal with.

There can be arguments about which foods can and cannot be eaten. Always being different from their brothers, sisters and friends and going out for a McDonald’s or a pizza can turn into a nightmare when your child, yet again, cannot eat all the yummy things available.

This can result in bad behaviour, temper tantrums and refusal to eat at all and this in turn affects diabetic control. Yes, living with diabetes and coeliac disease dies bring its stresses and strains to family life and these should not be underestimated.

Here are just a few tips we have picked up along the way

Eating Out – This can seem like just another obstacle to overcome, but it can be so don’t give up. Fast foods are enjoyed by children and we discovered that with a bit of forward planning they can still be part of our life.

Pizzas – We’ve discovered that most pizza bars are happy to put a topping on a gluten- free pizza base so you can always make your own base and take it with you.

Pasta – You can take your own gluten-free pasta with you and ask to have it cooked.

Burgers – McDonalds etc are always keen to oblige and will put a burger inside a gluten-free roll.

Fish – Can be fried without batter.

We always go armed with gluten-free bread and insulin wherever we go!

Holidays – Again it is a matter of ‘be prepared’ and we’ve discovered that time spent on forward planning is well worth it, whether holidaying in this country or abroad. If you are going abroad it is worth taking all your gluten-free products with you. If flying we have found that airlines will provide a gluten-free diet if ordered 3-4weeks in advance but, of course, there is never enough carbohydrate so we have to take extra.

School – School kitchens are usually very accommodating and are happy to provide a gluten-free diet but there may not be enough carbohydrate. I’ve found that catering staff are very willing to help once I have spent time with them explaining my son’s needs, although it is often easier and a safer bet for younger children and the newly diagnosed to have packed lunches.

An expensive tip – We’ve invested in an automatic bread maker and it makes delicious home made bread and prepares dough for pizzas, doughnuts, buns and pastry etc. It has brought a greater variety and freshness to the gluten-free diet and, even better, it has given my son a real interest in making his own recipes.

Help!
All this sounds pretty horrendous and it can be overwhelming at the beginning but I know from experience, that once you have got used to the idea of your child having coeliac disease and diabetes, it is possible to survive!

Information Sources

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Diabetes and Coeliac Disease

What is Coeliac Disease?
Symptoms of Coeliac Disease
Diagnosis
Diabetes and Coeliac Disease
Treatment – Diets For People With Coeliac and Diabetes
The Experiences of a Family With Diabetes and Coeliac Disease
Information Sources

 

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Information Sources

The following phone numbers and addresses may be a useful source of more information:

Coeliac UK
3rd Floor
Apollo Centre
Desborough Road
High Wycombe
Bucks
HP11 2QW
helpline: 0870 4448804
website: www.coeliac.org.uk

Another useful website is: www.allergy.co.uk

Depression and Diabetes

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Depression and Diabetes

Statistics
How do You Know You Are Depressed?
The Need for Diagnosis
Treatment
Depression in Parents of Children With Diabetes
GE Insulin, Hypoglycaemia and Depression
Useful Research – Depression and Diabetes

 

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Statistics

Major depression in the UK population at any one time is about 5%, although as many as one person in three may experience an episode of depression in their lifetime. The presence of other illnesses may complicate or worsen depression and vice versa.

Research has shown that depression may occur in:

  • Up to 60% of stroke patients
  • Up to 40% of people with Parkinson’s disease
  • Up to 42% of cancer patients
  • Up to 21% of people with irritable bowel syndrome
  • Up to 14-18% of people with diabetes

A study by Brazilian researchers, presented at the American Diabetes Association Conference 1998, showed that among a group of people with diabetes those whose HbA1c levels averaged less than 9%, only 21% tested positive for depression according to the results of a standardised test. By comparison of those with HbA1cs over 9%, 42% tested positive for depression.

The researchers used cognitive therapy to reverse the depression. In those people where depression improved, there was an average HbA1c of 8.3% while those who showed little improvement had an average of 11.3%.

Other research has shown that people with chronic conditions, including diabetes, are three times more likely to suffer depression than the general population.

Research now suggests an association between higher blood glucose levels and depression which can increase the risk of diabetic complications. It is also possible that high blood sugars cause the depression rather than depression causing high blood sugars.

An international report showed that having diabetes and depression has the greatest negative on quality of life compared to diabetes or depression alone, or other chronic conditions.
[Lancet 2007;370:851-8]

Many studies highlight the need to ensure that depression does not go undiagnosed. They also highlight the need to provide children, adolescents and adults with diabetes with greater psychological support and where necessary, a psychological assessment and treatment for depression.

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For more information on depression, please visit the NHS Choices website:

NHS Choices: Depression

How do You Know if You Are Depressed?

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Depression and Diabetes

Statistics
How do You Know You Are Depressed?
The Need for Diagnosis
Treatment
Depression in Parents of Children With Diabetes
GE Insulin, Hypoglycaemia and Depression
Useful Research – Depression and Diabetes

 

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How do You Know if You Are Depressed?

The signs of depression include the following:

  • No longer enjoying or being interested in most activities.
  • Feeling tired or lacking energy.
  • Being agitated or lethargic.
  • Feeling sad or low much of the time.
  • Weight gain or weight loss.
  • Sleeping too little or too much.
  • Difficulty paying attention or making decisions.
  • Thinking about death or suicide.

The Need For Diagnosis

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Depression and Diabetes

Statistics
How do You Know You Are Depressed?
The Need for Diagnosis
Treatment
Depression in Parents of Children With Diabetes
GE Insulin, Hypoglycaemia and Depression
Useful Research – Depression and Diabetes

 

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The Need For Diagnosis

Recent estimates suggest that up to three quarters of cases of depression in people with diabetes may go undiagnosed. This may be because of poor detection rates but it could also be that some people with diabetes don’t report their symptoms of depression because they see them as ‘just part of having diabetes’.

Screening for depression [not specifically for people with diabetes] has been recommended by national and international bodies and now in the UK, the Dept of Health recommends that all GPs use two simple questions to screen for symptoms of depression:

  • During the last month, have you been bothered by feeling down, depressed or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

If people answer ‘yes’ to either of these questions, they are given a questionnaire to answer to measure the extent and nature of the symptoms. It is important that similar methods are used in diabetes hospital clinics where many people with Type 1 diabetes receive their treatment.

Treatment

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Depression and Diabetes

Statistics
How do You Know You Are Depressed?
The Need for Diagnosis
Treatment
Depression in Parents of Children With Diabetes
GE Insulin, Hypoglycaemia and Depression
Useful Research – Depression and Diabetes

 

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Treatment

Treatment for depression in people with diabetes has been shown to be effective and has the additional benefits of improving blood sugar control. The evidence suggests that cognitive behaviour therapy and anti-depressant medicines are as effective in people with diabetes as in those without diabetes. One study found that not only did treatment improve blood sugar control but during treatment there was an improvement in mood and weight. So treatment for depression can improve blood sugar control, so reducing the risk of complications but importantly, it also improves quality of life.

So if you answer ‘yes’ to the two questions below:

  • During the last month, have you been bothered by feeling down, depressed or hopeless?
  • During the last month, have you often been bothered by having little interest or pleasure in doing things?

…or you have more mild symptoms, you are not alone and the clear message from research is to seek help from your doctor because there is a good chance that your life will improve.

Depression in Parents of Children With Diabetes – is it Surprising?

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Diabetes
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Depression in Parents of Children With Diabetes – is it Surprising?

A study [ref 1] has looked at depressive symptoms in parents of children with diabetes treated with intensive therapy [multiple daily injections] and with conventional therapy [twice daily injections]. It has shown that there are no significant differences in depressive symptoms in parents between those with children treated intensively and those treated conventionally.

The study did not show that parents’ depressive symptoms correlated with their child’s metabolic control, the duration of diabetes, age of the patient, age of the parent, family size or family income. The authors concluded that switching children to intensive therapy did not reduce the depressive symptoms in parents because as there was no reduction in depressive symptoms in the intensively treated group compared to the conventionally treated group. They suggest that as hypos are more common in intensive therapy, this may be a source of additional stress for the parents, so adding to their depressive symptoms.

The reality of what the study shows is that many of the things that were thought to cause parental depression actually don’t. It also shows that in some parents the depressive symptoms experienced at diagnosis do not go away as time passes.

As a parent could I dare to suggest that simply having a child with diabetes is something we never quite get over and this is why we show depressive symptoms. May be we don’t have to deeply search into why it happens! Let’s take a harsh look at the reality:

  • Your child is diagnosed with diabetes – a life-long condition for which there is no cure.
  • You have to face the reality that this is not a condition that even stays the same – there are always the risks of the complications at the back of your mind.
  • You have to live with the day to day worries of bringing up your child with diabetes and keeping the rest of the family happy.
  • You have to face the worries of hypos, at night, at school, when they are out socially, when they eventually leave home – this list is endless.
  • You feel a huge responsibility for your child’s future health and wellbeing and you can never quite get away from the feeling of guilt, however irrational this may be.
  • The longer you all live with diabetes, the more obvious it becomes that the hoped for cure is not around the corner and you even start to wonder whether there is real incentive to find that cure. You question the way in which research money for diabetes is spent.
  • We read that the death rates in people with diabetes have not reduced, so we have to question the effectiveness of present day treatment with all the apparent improvements such as home blood monitoring.

Is it surprising that we feel a bit depressed and that this depression is nothing to do with blood sugars, with time, with the age of our children or ourselves, with our income or our family situation? Some of these things may make it worse from time to time but underneath, we can never get away from the realities of diabetes. We need to be given some real hope. We need to see that research is going in the direction of making life better for those who already have diabetes as well as research into prevention. We need to be understood and heard and we need to see real progress in the treatment of diabetes for the sake of our children.
Ref 1 Diab Care, Vol 22, No 8 August 1999, 1372-1373 Depressive symptoms in parents in intensively treated children with diabetes compared to those conventionally treated

GE insulin, Hypoglycaemia and Depression – A Connection?

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GE insulin, Hypoglycaemia and Depression – A Connection?

A Personal Experience

Colleen Fuller, Canada
Two weeks ago I switched to pork insulin, and there are two main changes in myself that I’ve noticed. The first is that I haven’t had diarrhea for the first time in 3 years. That might not be associated with the insulin – and it’s only been the last several days, but I notice it, and I’m watching. I know that diarrhea can be a complication of diabetes, but I never had experienced it on an on-going basis until I began using GE insulin, and now it seems to be changing.

The second big thing is that my mind is energized. I just don’t know how else to explain it. When I switched to Humulin in 1996 I experienced six comas in a period of about one month and was hypoglycaemic most of the time for about six or seven months. My behaviour definitely did change and the one who felt the brunt of it was my husband. I became extremely aggressive and I also began accusing him of trying to control me and disempower me. This was based on one simple fact: I had no control! I could no longer tell when I was hypoglycaemic, but John, my husband, often could at that time. By the time I began showing symptoms I was long gone and helpless. So John would say “You need some orange juice” and I would begin screaming at him: “how would you know, you’re not a diabetic”. I was terrible, even telling him on several occasions how much I hated him. It was awful, awful, awful and I was miserable.

I began seeing a psychiatrist in 1997 and she diagnosed me with clinical depression. There was a lot in my own past that also came up during this time, including an ex who had committed suicide in 1974. But as I look back on it now, my view of this period is changing. One of the things I complained to the psychiatrist about was my inability to focus on anything. I was finishing a book, but I was really struggling with it. She said that was a symptom of depression. The doctor linked my depression to consistent hypoglycaemia. At that time I had depleted any reserves of glucose in my body – next to nothing in my muscles, organs or brain. This, she said, affected the seretonin levels in my body. Ergo: depression. The answer? Zoloft. No one recommended I stop taking GE insulin. But for a long time I refused to take an anti-depressant. I just didn’t want to take any more drugs – I couldn’t handle it. GE insulin was enough!

By then after blood tests showed that no, I wasn’t miraculously producing my own insulin and that was not the reason for the problems I was having – my endocrinologist wanted to switch me to Humalog and to an insulin pump. You have to understand that I was desperate, and also I now believe that my brain wasn’t functioning properly – otherwise I would have began insisting on being switched back to animal insulin. (I unquestioningly accepted that I “couldn’t” take it any longer because it was being withdrawn – something completely out of character. I didn’t even research the subject, and research is what I do for a living.)

Anyway, I did accept his advice and switched to Humalog and to the pump. After two days on the pump I was still hypoglycaemic all the time. I remember sitting at the table in our dining room all alone, in tears. I felt overwhelmed with diabetes and I thought “my life used to be more than this”.

Diabetes had always been there, but it had never dominated my life – my life was made up of other things like love and work. My logic then proceeded like this: I don’t want this life, but is there another life for me? Is it this life or no life? I felt there was no other life, and that I would forever more be poking my fingers every 30 minutes and chugging apple juice, waking up surrounded by paramedics and that I would lose my autonomy and independence. I wanted to die – I don’t know if I wanted to commit suicide, but I definitely didn’t want to live my life any longer.

I didn’t tell my husband I was feeling this way, but when I saw my psychiatrist I told her and she seemed upset, and really insisted that I begin taking the Zoloft. So I did, because I was upset, too. Suicide was something I’d had to deal with in the past, and so it frightened me to think of myself veering in that direction. She also counselled me to give the Humalog and the pump a chance. These things all probably helped me: the Zoloft, my psychiatrist and the insulin pump, not to mention my family and my husband.

Then about six months ago I began to experience this inability to concentrate or to focus on anything. I don’t know exactly how else to describe it. But I’d stopped seeing the psychiatrist by then, and I’d been off the Zoloft for a while. I didn’t want to get back into that routine, I guess I just wanted to get on with my life. So I ignored it. But it got worse and worse, and ultimately this is what forced me to finally switch back to pork insulin. I’d been reading quite a lot about GE insulin and its possible link to depression in some people. I could feel myself moving in that direction again, mainly, I think, because of this focus thing. I can’t write when I can’t focus. I’d been missing deadlines during this period, which is really terrible.

Lo and behold! I have been more productive in the last week than I have been for months. It might have nothing to do with the insulin, but that’s the only thing that’s changed for me. I feel energetic and very, very focused.

Perhaps that sounds all airy-fairy, but it’s how I feel. When I told my endocrinologist, who I credit with saving my life and who I greatly admire and like, that I wanted to switch back to pork, he was surprised. He didn’t even know animal insulins were still available. But he said the only important thing is how I feel. My blood sugars have always been excellent, both on animal insulin and on GE insulin – except during that bad period when my HbA1C’s were extraordinarily low. (That’s when they began testing me for endogenous insulin.) So, he said, as long as my overall control is good, he himself is not wedded to the GE insulin. “I’m not a salesman for the drug industry,” he said.So there’s my story with insulin and depression. I’d never been depressed before I went on to GE insulin, or at least I’d never been diagnosed with it. I feel that by switching back to pork insulin I’ve been able to avoid taking an anti-depressant. I feel better and more energetic and more focused. I should also just add that the other night I woke up sweating and hypoglycaemic. I was so happy! This hasn’t happened for quite a long while. I trotted downstairs and gulped down a glass of orange juice!

I will never, ever go back to taking GE insulin.

Useful Research – Depression and Diabetes

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Depression in Parents
GE insulin, Hypoglycaemia and Depression
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Useful Research – Depression and Diabetes

Research in young adults with Type 1 diabetes
Research in Australia surveyed 92 young adults with Type 1 diabetes with an average age of 22 and found that 35% of them reported depressive symptoms. Importantly those with depression tended to have poorer blood glucose control than those without depressive symptoms, so putting those with depression at greater risk of complications such as cardiovascular disease. [Diab Med, 2008;25:91-6] The study concluded that as many young adults reported significant levels of psychological distress, health teams caring for young adults with Type 1 diabetes should provide psychological assessment and support.

Research in older people with diabetes
Research in Canada has shown that people with heart disease maybe at risk of further attacks if they suffer from depression or anxiety. People with diabetes are more at risk of developing heart disease, so this study again emphasises the importance of treating depression in people with heart disease as well as those with diabetes.
[Arch Gen Psychiatry 2008;65:62-71]

Research in the US looking at the relationship between diabetes and depression found that depression treatment reduces mortality by half in older people with diabetes. Again this emphasises the need to diagnose and treat depression in people with diabetes.
[Diab Care 2007,30:3005-10]

Depression link with poor blood glucose control
Research has also shown that in young people with Type 1 diabetes, depression tended to be linked to poorer blood glucose control. This could be through hormonal changes but it is thought that the most likely cause is the negative effects that depression has on people making self-management of their diabetes more difficult with the following effects:

  • lack of exercise
  • increased smoking and alcohol consumption
  • lack of or poor blood glucose monitoring.

Research using questionnaires has shown that depression in people with both Type 1 and Type 2 diabetes may have the following effects:

  • They are less likely to eat the types and amounts of food recommended.
  • Less likely to take all their medications.
  • Less likely to function well, both physically and mentally.
  • Greater absenteeism from work.

[Archives of Internal Medicine, Nov 27, 2000]

Note: Depression is also associated with increased weight and obesity and depression itself can cause Type 2 diabetes.

Injection related anxiety in insulin treated patients
This study set out to look at whether the presence of injection related anxiety and phobia influences compliance, glycaemic control and quality of life in people with diabetes. 115 unselected insulin treated people, 80 with Type1 and 35 with Type 2 diabetes, completed a standardised questionnaire providing injection anxiety scores and general anxiety scores. The results showed that in14% of cases injections had been avoided because of anxiety and 42% expressed concern at having to inject more frequently. A significant correlation was found between injection anxiety scores and general anxiety scores. The latter was significantly associated with injection avoidance and expressed concern at increased injection frequency. No significant correlation was seen with HbA1cs and either type of anxiety. The authors conclude that symptoms relating to injection anxiety and phobia have a high prevalence in an unselected group of people with diabetes and are associated with higher levels of general anxiety.
Diabetes Res Clin Pract 1999 Dec;46 [3]:239-46

Prevalence of symptoms of depression and anxiety in a diabetes clinic population
While waiting for their routine hospital appointment adults with Type 1 and Type 2 diabetes were asked to fill in a questionnaire to measure psychological symptoms and the perceived need for psychological support. From the patients records the presence of complications was recorded and the HBA1 was also recorded. The response rate was high [96%]. The presence of psychological symptoms was also high with 28% of the participants reporting moderate to severe levels of depression or anxiety or both. Men were more likely to report moderate to severe depression symptoms and women more moderate to severe anxiety symptoms. There was a significant link between depressions and poor gylcaemic control, as measured by the HbA1, in men but not in women. A third of the participants reported that at that moment they would be interested in receiving counselling if it was currently available in the diabetes clinic. The authors conclude that there is a significant proportion of people who require psychological support which, if available, might help to improve glycaemic control and so overall wellbeing.
Diabetic Medicine, March 2000, 17; 198-202

Stress and Diabetes

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The most frequently occurring mental health problems incorporate depression and anxiety. They cause impaired functioning and make up about 1 in 5 primary care consultations. [McManus et al, 2009. Results of a household survey]

Many people do not seek treatment and when they do, their conditions are often not identified. According to NICE [2009], 90% of depressive and anxiety disorders that are identified are treated in primary care, by the GP.

The findings from the latest national psychiatric survey for England shows the following prevalence of common disorders at a given point in time:

  • 1.1% have panic disorder [panic attacks]
  • 1.4% have phobias
  • 2.3% have depression
  • 4.4% have generalised anxiety disorder

It is well recognised that people with long-term conditions such as diabetes, are more likely to suffer from depression. Just living with diabetes means that they are also more likely to be in stressful situations or to suffer with anxiety. This section provides information about stress, anxiety and depression.

Exercise – it is well worth remembering that taking physical activity helps to relieve depression, stress and anxiety, even if you don’t feel like it!

How the Body Handles Stress

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How the Body Handles Stress
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How the Body Handles Stress

The body handles stress in much the same way as it handles danger and there are three stages to this.

Fight or flight stage
Any danger or stress triggers the release of adrenaline and other hormones into the blood stream and it is these hormones that enable the body to defend itself. Breathing and the heart rate increase and blood pressure rises pumping more blood to the muscles so that they are ready for action. This is when the blood sugars rise. If the stress is eliminated at this stage, then the body relaxes and goes back to normal.

Resistance stage
Some stressful situations cannot be eliminated at the fight and flight stage, for example a job you hate or deteriorating health. At this stage the stress becomes chronic. The body continues to fight the stress by releasing high levels of the stress hormones even though the fight and flight responses have worn off and breathing and the heart rate may be normal. This is when symptoms appear, such as anxiety attacks and/or mood swings – feeling of being ‘stressed out’.

Exhaustion stage
This stage occurs when the effects of chronic stress affect health. The immune system does not work as efficiently making people vulnerable to infections. The continual long-term fight against stress reduces the body’s energy stores so that there is fatigue. This may be followed by depression, sleeplessness and poor appetite. This is when blood sugars, blood pressure and cholesterol levels may become more difficult to control and there is a risk of heart attack.

Stress and Blood Glucose Levels

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Stress and Blood Glucose Levels

Under stress the body produces hormones including adrenaline, the most commonly known one, often called the fight and flight hormone. These hormones cause the body to release stored glucose and fat for the extra energy which is required to deal with the stress. However, they can only be used providing the body has enough insulin. It is this sudden extra production of glucose in people with diabetes that causes the blood sugars to rise. This can be made worse by the way many people react to stress – by overeating or by taking less exercise because of the lack of energy. It may be necessary to increase your insulin dose or the other alternative of course, is to take more exercise. Exercise will not only help to reduce your blood sugars but is also recommended as a method to help people cope with the stress itself.

Personality, Stress and Blood Glucose Levels

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Personality, Stress and Blood Glucose Levels

In a study, published in the June issue of The Journal of Health and Social Behaviour, researchers examined the behaviour, personalities and blood sugar levels of 57 people with Type 1 diabetes and 61 with Type 2 diabetes. The participants were divided into two groups according to personality types – self-controlled types and reactive emotional types. The results showed:

  • People with Type 1 diabetes appear to be more susceptible to physical harm from stress.
  • Among the Type 1 group the self-controlling types had better blood glucose control under stress and the emotional reactive types had worse control.
  • In Type 2 diabetes where some insulin is still being produced, the body’s ability to automatically manage its own affairs is impaired but remains in tact.

There may be little that we can do about our personality but understanding ourselves and what is happening to us can help to reduce the effects of stress.

What is Stress and How Does it Affect us?

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What is Stress and How Does it Affect us?

An article by Dr David Lowenstern in ‘Reading Out’, the journal of the GBS Support Group explains this very well:

  • Stress is something that interrupts our routines and causes us to change. It is disquieting and distressing.
  • We develop routines and habits of doing things and anything unexpected or unfamiliar is a stressor.
  • A stressor can be useful up to a point as it increases our performance and encourages us to strive and cope with difficult things. There may come a point when it becomes difficult and we can cope no longer. This happens with long standing conditions or illnesses [like diabetes].

What happens when we get very stressed?
We have a stress reaction which may be an automatic nervous system response affecting our blood pressure and heart rate causing sweating. But there may be other psychological effects that are not so easy to deal with, such as depression and frustration [diabetes can be very frustrating, as can be many long-term conditions!]

Depression and frustration are expressed in many different ways:

  • We embellish things, fantasies run wild and we start feeling things that aren’t actually there [ eg imagining the whole world is against us or that people are talking about us].
  • We get anxious and worried about things that might happen.
  • We get angry and very, very angry.

How often are we encouraged to be angry?
Dr Lowenstern points out that this is very rare because we become seen as rude and impolite and are avoided by other people. But every time we feel anger and we don’t express it, we are being rude and impolite to ourselves.

The stiff upper lip, keeping things bottled up and doing the right and proper thing, is not necessarily the best thing to do because stress comes out in other ways. It builds up like steam in a pressure cooker with the vent closed and then it blows. This is what happens to us if we keep the stiff upper lip at a time of stress – our feelings and frustrations spill over and our families tell us we are very difficult to live with. This is something we cannot always see for ourselves.

How do we cope with stress?

This depends on several factors:

  • Our own particular style of coping.
  • The time scale.
  • Our inherited ability to cope.
  • The availability of support.
  • How much control we can retain.
  • What kind of stress we are under.

There are 4 main coping styles with stress or a crisis:

Denial – When we don’t want to know about it, we are told but we shut our ears. This can be helpful because it gets us through the day and protects us, but it can be obstructive and self-defeating. For example, the diagnosis of diabetes is stressful and can cause denial but if the denial extends to actually not taking the prescribed insulin, then there is a very real problem.

Regression – This is when we use what is tried and tested from the past. We become younger and tend to be child-like. Very competent people when faced with what, to them, is an awful situation can be reduced to crying like a baby – even though this doesn’t sort out the problem.

Inertia – This is just giving up thinking, with statements like “What’s the point?” or “It’s all too hard”. Inertia does not get us very far, it’s infectious and may cause our family to give up too.

Mature problem-solving – This is a mixture of expressing our feelings about what is going on, trying to realistically weigh up what is happening and finding some sort of acceptance of it within ourselves. It is not giving up, not losing all the fight within us but accepting the situation.

For many of us being able to talk and share our experiences or our worries is the way we deal with stress. Women are often far better at this than men because men tend to believe that they are strong or are expected to be strong. So men are much more likely to be the pressure cooker with the vent closed.

The clear message from Dr Lowenstern is:

“Keep talking, don’t be silent. If you feel like crying, cry and if you feel angry, be angry. Don’t keep quiet as far as doctors are concerned – keep sticking up for yourselves and remind yourself that it is your body and your life and you have a say in it. Retain some sense of control of what is yours but at the same time recognise that there are some limitations, especially as you get older.”

Quote from a parent: “With mild stress I know I clean the house furiously from top to bottom. I also know the value of previous experience. When my daughter was diagnosed with diabetes I found it very stressful and when I got divorced some 10 years later, I also found this very stressful but I recognised the same feelings – denial, anger, grief, the sense of loss. I knew I had coped the first time and I could, therefore, cope the second time as I had previous experience of a very stressful situation.”

Ten general tips for coping with stress

1. Avoid self medication with nicotine, too much coffee, alcohol or tranquillisers
2. Work off stress – physical activity is a terrific outlet.
3. Don’t put off relaxing.
4. Get enough sleep to recharge your batteries.
5. If you become sick, don’t try to carry on as if you are not.
6. Agree with somebody – life should not be a constant battle ground.
7. Learn to accept what you cannot change.
8. Manage your time better and learn to delegate.
9. Know when you are tired and do something about it.
10. Plan ahead by saying ‘no’ now. You may prevent too much pressure piling up in the future.

In Diabetes Interview Nurse Janice Betz simply recommends five ways of handling stress and perhaps the last recommendation is the one we should try to remember, even when times are hard:

  • Exercise
  • Adequate sleep
  • Relaxation techniques
  • Getting a massage
  • Maintaining a sense of humour!
InDependent Diabetes Trust
IDDT