Winter 1996 Mission

Walking a tightrope

Diabetics struggle to find the right balance in lifestyle choices


By Suzanne DuBeau

Five years after finding out he had non-insulin dependent diabetes, Warren discovered a disturbing pattern. "I've been trying to ignore it, but the correlation is just too strong," he told a friend. "When my blood glucose level gets too high, I get depressed."

His doctor had cautioned him about the many complications of diabetes, but depression wasn't on the list. Warren, then in his mid-30s, already had experienced "fairly regular bouts of depression" for a couple of years before he was diagnosed. He wondered if surging levels of glucose also had been responsible for those prediagnosis emotional lows.

Talking with other diabetics, Warren found that depression was a common experience. Daily exercise seemed to keep his blues at bay and his glucose level near normal, but he was concerned about his treatment options if he became severely depressed.

"It's a good idea for diabetics to monitor their feelings as well as blood glucose," says Linda Rhodes, MD, assistant professor of psychiatry at the Health Science Center. "People with diabetes should become aware of signs of depression (lingering sadness, withdrawal from friends and family, excessive guilt, etc.) and discuss any emotional problems with their doctors.

"Diabetics go to the eye doctor, the heart doctor, the foot doctor. If they're depressed, they figure there's one more thing wrong with them and hope it'll go away," says Dr. Rhodes. But emotional problems don't always go away. Like physical complications, they may get worse if not addressed promptly," says Dr. Rhodes, who knows firsthand the importance of treating the person, not just the disease. She was diagnosed with diabetes at age 13.

"When you're depressed, you have little energy and things hurt more. You just don't feel well and blood glucose control suffers, resulting in an endless destructive cycle of depression and physical complications," she adds.

"Feeling fatigued, lethargic and even depressed are common presenting signs of diabetes," says Ralph DeFronzo, MD, professor of medicine, chief of the diabetes division, and deputy director of the Texas Diabetes Institute in San Antonio. "People with high blood glucose levels don't feel like dragging out of bed in the morning. They don't feel well, but they don't know what's wrong.

"When we get these patients on treatment (diet, exercise, medication) and bring their blood glucose levels down, we often see a major change in disposition," said Dr. DeFronzo.

Some studies indicate depressed people with diabetes have worse blood glucose control than diabetics who aren't depressive. Researchers also have found that stress affects diabetes and can cause a person's blood glucose to fluctuate, but they don't know why.

Physical stress such as illness or injury definitely plays havoc with blood glucose levels. "The body responds with a burst of hormones that cause insulin resistance in diabetics," Dr. DeFronzo explains.

Insulin resistance occurs when the body stops responding to insulin. As a result, the pancreas can't produce enough insulin to keep up with the tissue demands for insulin. Glucose builds in the bloodstream instead of entering the cells to nourish them. Over time, high blood sugar levels are to blame for heart, eye, kidney and peripheral nerve damage. The jury's still out on the relationship between mental stress and blood glucose levels, Dr. DeFronzo says.

"For reasons we don't understand, mental stress affects people differently. The overall effect isn't uniform." However, he acknowledges that some patients may experience blood glucose control problems due to mental stress.

Julie Meyer, RN, associate professor of chronic nursing care and diabetes clinical nurse specialist, has worked with diabetic patients for 15 years. Meyer, who holds a master's degree in mental health nursing, says depression in people with diabetes is getting greater attention from health care professionals today. An estimated 15 million Americans have diabetes. Diabetes is now the fourth leading cause of death and the second leading cause of visits to physicians in the United States.

"No other disease requires so much active participation from patients," she notes. "Every time they check their glucose, every time they eat or drink something, they are constantly reminded that they have a chronic, incurable disease. Fear of the future or frustration about the present is stressful."

"Having diabetes is a drain physically, emotionally and financially (the cost of monitoring, medication and medical checkups)," Meyer says. "A question on our clinic survey asked patients if they were depressed about having diabetes. More than a few burst into tears and opened up about their feelings of helplessness and sadness."

Meyer says she's found two groups of diabetics particularly prone to severe depression young people facing life transitions and middle-aged, Mexican American women who are accustomed to putting family first. She's seen more than a few patients depressed to the point of contemplating suicide, she adds.

Focusing on present good health, keeping a positive outlook, staying active and joining support groups can help diabetics dodge depression or decrease its demoralizing effects, she adds.

Physicians agree that depression can be treated safely and effectively in diabetics. Exercise can keep mild depression in check. It improves self-image and physical health, increases endorphins (mood-enhancing chemicals in the brain) and lowers blood glucose.

Counseling and medication are successful, too. Serotonin re-uptake inhibitors (such as Prozac, Zoloft and Paxil) are good antidepressant choices for diabetics with depression, according to physicians, because these medications have few side effects and drug interactions and may minimally affect blood glucose levels.

Persistent depression that does not go away should be evaluated, not accepted as an untreatable part of diabetes, Dr. Rhodes says. "We all learn to live with diabetes, but no one should live with untreated depression. Treatment can make a real difference in someone's life."

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