Prolonged exposure to stress and general overactivation of the "fight or flight" response has strong evidence supporting a role in the creation of belly fat as well as a metabolic & inflammatory environment conducive to type 2 diabetes, immune dysfunction, and related problems (1; 2; 3; 4; 5; 6; 7; 8; 9).
From mostly rat models, we understand that poorly controlled diabetes is associated with high levels of cortisol throughout the day. This leads to disruptions in neurotransmitter balance (6; 15) and the regulation of stress at the level of the brain in a system known as the hypothalamus-pituitary-adrenal (HPA) axis (16; 17).
When the body is exposed to high levels of cortisol, insulin and other hormones, it may have trouble regulating the body’s ability to respond to stress:
1.) The HPA system can be put in overdrive, putting a stress on body resources, and "cross-talking" with other hormones (especially sex hormones like estrogen/testosterone) to compensate production for the high demand for cortisol (18; 19; 20).
2.) A vicious cycle can develop, that if allowed to persist, may affect the function of numerous body systems (thyroid, liver detoxification, menstrual cycles, sexual health and arousal, bone health, muscle weakness, sleep, energy, etc) and the ability of a person to respond appropriately to stress in the first place. This decreases quality of life and may lead to chronic disorders such as depression, chronic fatigue, and mood swings.
3.) Blood sugar can be rebalanced (such as insulin therapy), but the disruptions at the level of HPA regulation in the brain can remain (21).
Studies tend to focus on links between depression and type II diabetes, but few mention the influence of emotional stress (which is also linked to depression) and type II diabetes.
In general, emotional stress, anxiety, sleeping problems, anger, and hostility all have been associated in the research literature with an increase the risk of developing type 2 diabetes (14)!
Upon a closer look, emotional stress may just be the “elephant in the room” when it comes to care for not only uncontrolled diabetes, but other chronic disease processes as well.
Conventional Strategies - Well-Intentioned, but Miss the Mark
Before functional nutrition, stress was usually handled with vague prescriptions to “get more sleep”, “take it easy”, and to “consider” meditation or counseling.
When these attempts failed, clinicians typically turn to anti-depressants, anti-anxiety medications, muscle and nerve relaxers, or sleep aids to help someone manage their stress.
These recommendations can get a person through their day and may be necessary to allow you to continue working and participating in your life, but (preventable) dependence on medications to get you through your day does not fit my standard of health maintenance and promotion.
It is not in my scope to discuss the pros and cons of medications, so please ask your prescribing doctor if you have questions about individual medications. Some individuals surely depend on these medications to live productive lives, and so it is important to keep case-by-case circumstances in mind.
Functional Medicine and Emotional Stress
Functional medicine clinicians are learning that relatively common patterns may underlie stress and emotional imbalance can include (but are not limited to):
- Low essential fatty acids (omega 3 fatty acids found in fish, nuts, flax, algae...) (22).
- Vitamin D deficiency
- gastrointestinal imbalance
- oxidative stress and antioxidant status such as glutathione (5)
- altered blood sugar control
- adrenal insufficiency, HPA overactivation
- exposure to environmental toxins/metals
There are other factors involved in stress and blood sugar that go beyond the scope of this article.
- Herbal & supplemental therapies for stress and blood sugar support like green tea (23)
- Exercise and physical activity and the important role they play in stress management and contribute to weight loss, improved blood pressure, improved cholesterol and triglycerides, and reduced risk of developing diabetes (24).
- Social factors and coping skills, having supportive friends and family members, experiencing a history of physical or emotional abuse, as well as economic insecurity, food insecurity, or career stress all play important roles in the management of stress (5).
Why is Stress Overlooked in Diabetes Care?
You might begin to understand how health professionals are failing to see diabetes in full context of our social and personal lives.
You may also see how lifestyle may actually fuel the “rollercoaster ride” of poorly managed blood sugar.
Behavioral and lifestyle recommendations are seldom made with a full understanding of your personal barriers and limitations - nor are these types of considerations prioritized in the context of clinical care.
When you’re stressed, there are other psychological effects at play:
- You may be less likely to comply with complex medication or supplement schedules.
- Those under high levels of emotional stress may also experience cravings for unhealthy foods high in fat, salt, and refined sugar.
- Insulin pumps and other technological advancements in diabetes care not only still require finger pricks as a safety check, but also do not always account for special situations of acute stress, as well as some of the more obvious events such as forgetting to keep a snack on hand, or eating a meal excessively high in simple carbohydrates.
Keeping your blood sugar within healthy ranges is an important aspect of care for those with blood sugar problems, but laboratory values have little value without being interpreted in full context of your lifestyle & personal health history.
A significant number of persons living with diabetes also deal with eating disorders, anxiety, depression, and sexual problems that are all associated with improper blood sugar regulation (25).
There psychosocial implications of type 2 diabetes that create a “vicious cycle” -- Emotional stress not only may be a metabolic trigger of poor blood sugar control, but reciprocally, also may make it difficult for you to comply with complex lifestyle, dietary, and pharmaceutical recommendations in the first place.
Pre-natal and Infant Exposure to Stress:
It is hypothesized that maternal stress can influence the development of several body tissues. Maternal stress during fetal and infant development is one element that has been associated with obesity and insulin resistance.
It is now substantiated by a growing body of research that stress exposure during key periods of development may influence genetic & metabolic programming - predisposing an individual to health problems later in life (26; 27).
For instance, hormones such as insulin, leptin & cortisol/corticosterone have been shown to have ability to cross the placental-fetal barrier (28).
While the details are still being worked out, it is suggested that aromatherapy, supplements, music, massage, and other complementary and alternative medicine therapies may play a helpful role in reducing maternal stress (26).
Evidence Supporting Stress Management and Diabetes:
Stress management therapies are time-intensive, costly, and difficult to scale, but group stress management programs such as mindfulness-based stress reduction have been shown to be partly effective at improving blood sugar control, possibly even more in those who report high anxiety before beginning treatment (27; 28).
Stress Induced Diabetes
"Glucocorticoid" drugs such as hydrocortisone and prednisone are similar in structure to cortisol (also a "glucocorticoid"). These types of drugs are often used therapeutically in adrenal, allergic, inflammatory and autoimmune disorders, but used chronically may also cause the same disorders the drug set out to treat (32)!
Glucocorticoids also have a suppressive effect on the hypothalamus and pituitary. The brain sees the synthetic hormone levels, and tends to "turn off" signals to produce the hormones naturally.
Because of this, “withdrawal” reactions following glucocorticoid therapy are common, and patients are typically weaned off of the drugs, and it can still take time for stress-responsiveness to normalize (37).
Chronic exposure to cortisol can act similarly.
Non-pharmacological interventions have been urged by some researchers to reduce "polypharmacy" (being on multiple drugs), save costs, and reduce prescription drug side effects and adverse reactions.
For instance, moderately intense physical activity shows promise as an alternative approach, but also in reducing the use of anti-diabetic drugs and drugs used to treat risk factors in obese individuals with type 2 diabetes (38).
Social Approach to Stress Reduction
Modern life is characterized by high demands, rapid pace of life, and efficiency and competitiveness in a global economy. Our lack of rest, recovery and restitution may be more problematic than the actual stress itself (39).
But beyond the intricate metabolic pathways at root behind chronic diseases such as blood sugar dysrgulation, sometimes the "solutions" have nothing to do with the body, but everything to do with society.
It is believed that biological, psychological, and sociological stress may all work together to influence health risks in those with diabetes type 2 (40).
When it comes to chronic disease, a "one-size fits all approach" simply does not exist. Recommendations need to be chosen and prioritized uniquely for each individual based on the uniqueness of their life circumstances. It takes time, it takes trust between provider and client, it requires healthy internal and external behavioral triggers, and it definitely takes support outside of the consultation room.