“Results of longitudinal studies suggest that depression, general emotional stress and anxiety, sleeping problems, anger and hostility are associated with an increased risk for the development of Type 2 Diabetes”, commented a report back in 2010 by the European Depression in Diabetes Research Consortium.
Our article this week is provided by Dr David Morris, who in the past few months has provided us with two blogs demonstrating how insulin resistance and Diabetes are clear examples of conditions that can be prevented and potentially reversed through non-pharmaceutical and lifestyle based approaches (you can find links to both of these article at the bottom of this page).
This week David looks at the role of the mind in reversing insulin resistance, and scientific mechanisms by which our emotions and stress levels contribute to the onset of insulin resistance; a condition that frequently leads onto Type 2 Diabetes.
Cognitive and Emotional Approaches to Reversing Insulin Resistance
Having already elaborated upon the role of diet and exercise to lower insulin resistance and hence prevent/reverse or improve Type II Diabetes in previous posts, in this post I will outline strategies to manage the mind and emotions as an important piece in the jigsaw.
It can become very easy if we practice nutritional or functional type medicine to lose track of the role that emotions play in disease and health. I believe that there is a dynamic interaction between our emotional state, beliefs etc. and our physical health.
There is no doubt whatsoever that physical issues, such as nutritional deficiencies, have a significant impact on “mental” health but also the flipside is true where our emotional state of being impacts tremendously on our physical health.
As part of a genuine holistic approach to health we need to understand and incorporate emotional/mental health in any strategy if we wish to be fully successful.
There have been numerous studies showing that stress is a risk factor for developing Type II diabetes. For example a 35 year study in Sweden of more than 7,000 middle aged men demonstrated that perceived stress is associated with increased risk of diabetes independent of other diabetes risk factors 1.
It is worth elaborating that the word “perceived” is crucial here – when levels of illness or diseases are measured after going through so called stress events, such as bereavement, job loss etc., then there is no correlation between stressful events and illness. The correlation only occurs when we measure people’s actual perception of these events. This is easy to understand as we all know that different people react very differently to exactly the same circumstances and it is the individual’s response to events that matters. This of course highlights that there is an opportunity to alter our inner response, even though we are often not able to alter our outer circumstances.
The link between being stressed and increased diabetes risk is easy to elucidate. Stress is of course a normal human reaction – we all know the feeling when we are suddenly shocked with our heart racing, sweaty palms, deep breathing and senses all alert. This is a helpful, indeed a necessary response, for survival i.e. the so called flight or fight response. As well as rapid changes in the firing of our nerves it involves a cascade of hormones including adrenaline and cortisol (our natural steroid).
In an ideal world, once the immediate threat is over, all of the chemical changes rapidly reverse back to a low level and there are no long term consequences. Prey species, such as antelope, demonstrate this nicely with a return to a relaxed state within minutes of a predator threat.
Unfortunately for us modern humans we tend to live in a state with almost constant stress. Even if we do get exposed to a short sharp stress such as being dangerously cut up by another car, then we rarely have an immediate chance to run and burn off the excess hormones. Instead we quietly (or otherwise!) fume away. In addition to this, many of the “threats” that trigger this stress response come from our own thoughts and worries that potentially never go away.
So once we are in a state of chronically raised cortisol then this directly antagonises the effects of insulin and raises blood glucose levels. It makes sense then that any technique that reduces stress should improve diabetes control.
Scientific studies back this up, and – although many of them are expensive in terms of both money and time resources e.g. Individual counselling and support – in fact simply 5 sessions of group education on stress management has been shown to have a long term benefit on diabetes control.2
The term stress management of course is rather vague and there are any number of successful techniques. Below are two simple techniques that I routinely advise in practice that are proven to be effective.
Progressive relaxation is a simple technique of relaxing the body by bringing our awareness to it. In the course of daily life chronic tension builds up without conscious awareness and it is only when we draw attention to our body that we can tune in and release this tension. The tension arises as a basic response to prepare our bodies for potentially dangerous situations but this also feeds back to our mind that we should be on the alert – a relaxed mind cannot exist easily in an unrelaxed body.
In progressive muscle relaxation exercises the process is to tense up particular muscle groups and then relax them, working progressively all of the way through the different parts of the body so that ultimately all muscle groups are involved.
This should be done in a time and space where you can relax and be comfortable without interruption. It can be done sitting or lying as pleased and it helps to start by calming the breath aiming to breathe gently into the belly.
The first step is applying muscle TENSION to a specific part of the body by focussing on the target muscle group, for example the left hand. Next, take a slow, deep breath and squeeze the muscles as hard as you can for about 5 seconds.
It is important to really feel the tension in the muscles, which may even cause a bit of discomfort or shaking BUT do not injure yourself! Take care with any parts of your body that are already sore!
The second step is RELAXING the tensed muscles. Keeping your awareness on the targeted muscle group, quickly relax the tension while breathing out. Allow the muscle group to remain consciously relaxed for 10-15 seconds.
Then move on to the next muscle groups – you should work your way from your head/face in to the back etc. and down the arms and then legs until the whole body has been involved. With practice isolating the specific muscle groups becomes easier.
Once completed enjoy a few moments of deep relaxation!
Please note: It helps to deliberately focus on the difference between tension and relaxation – this is important as trains the mind to become much more aware of hidden tension developing in daily life. Neuroscience is teaching us that we hugely limit the amount of sensory input we register consciously – this is called “gating” – and this is why we lose awareness of our bodies and underlying tension/discomfort. To understand this a little clearer- trained musicians, for example, will have a much greater level of awareness of musical sound and might be able to tell instantly that that 4th flute on the left is a little flat but this would missed by the majority of us. The only difference is the level of consistent awareness that a musician brings to music – similarly consistent awareness of our body will lead to us addressing tension before it becomes a chronic problem.
It doesn’t take much of this technique to have a positive effect – in a tightly controlled inpatient study just five days of progressive relaxation had a statistically significant impact on glucose tolerance3.
In my daily work in General Practice I encounter numerous people with anxiety and stress concerns and in over 15 years of checking I have universally found that they all are chest breathers and never use their diaphragm to breathe i.e. they have forgotten how to belly breathe.
Relearning how to breathe into the diaphragm is a simple and effective way to trigger the relaxation response. I say relearning as this should be our natural way to breathe as is shown nicely by a baby’s belly going in and out as they breathe.
Diaphragmatic breathing has been shown to decrease oxygen consumption, decrease heart rate and blood pressure and increase theta wave amplitude in EEG recordings. Essentially it leads to direct stimulation of the parasympathetic nervous system, at least in part because the diaphragm is innervated by the vagus nerve.
The best technique is to lie on your back comfortably with your hands resting gently on your belly – you need to then take a breath in and consciously ensure that your hands rise upwards with the breath in. You should then relax and let the hands to drop down with the belly as you exhale. This should be done evenly and regularly for about five minutes.
In a trial of 123 patients who had 3 months of diaphragmatic breathing added to standard care for diabetes, a significant improvement in diabetes control was shown to occur alongside a decrease in body mass index and an improvement in other metabolic markers4. Breathing practice was done between 15 and 20 minutes daily, twice a day, four days a week, for three months.
Rest and Sleep
I am never quite sure where to discuss sleep and rest – in many ways it is the flip side of exercise but is also part of restoring the mind as well as the body so I will discuss it here.
So how much sleep do you need?
A minority of people can get by with around 4 hours sleep a night – about 1 in 10,000 – Margaret Thatcher was famously one of them – but the majority of us need between 7 and 9 hours according to the National Sleep Foundation in the USA. They surveyed 300 studies and established that around 8 hours is a requirement for most adults hence the recommendation of 7-9 hours.
However the National Sleep Foundation 2011 survey, revealed how serious and widespread a problem sleep deprivation is – nearly 15 % of people get fewer than 6 hours sleep on weekdays, and 70% get fewer than 8 hours. All in all two thirds of people reported getting less sleep than they would like5.
Why is sleep deprivation bad for you?
Common sense (and scientific surveys) tells us that you are much less likely to make sensible lifestyle choices if you are tired – tired people snack more and exercise less (and the snacks are rarely healthy!!). This is not simply about lack of willpower as sleep deprivation reduces your levels of the hormone leptin – leptin acts to suppress appetite– and alongside this sleep deprivation raises the levels of ghrelin; the appetite stimulating hormone!6
Secondly there are other hormonal changes from sleep deprivation that directly raise insulin resistance. It appears to be missing the late phase of sleep that triggers this problem. To understand why it is worth looking at what happens to glucose and insulin during sleep.
Blood glucose rises by up to 30% in the early stages of sleep as the brain and muscle activity slows down and consequently insulin levels rise to counteract this. Insulin can rise by up to 50% and is at its maximum around the middle of the sleep period.
During the later stages of sleep cortisol levels fall and this improves insulin sensitivity so that blood sugar levels fall to the same as waking level. Missing this phase of sleep leads to cortisol remaining high and hence insulin resistance remaining high7.
It does not take long to trigger problems – just one shortened night of night of four hours sleep has been shown to increase insulin resistance.8
The Power of Belief
It may seem almost frivolous or even a bit “whacky” to talk about the power of belief but I have witnessed numerous occasions where people’s belief has kept them alive and well long after all medical prognosis has indicated they should no longer be alive. Similarly I have seen the reverse where a belief that they are unwell has led to patients’ death even though there has been no physical reason for this.
Our minds are far more powerful than we realise and in fact what we believe and think can be as powerful, or potentially more powerful, than what we actually do. This should also remind us to be careful in the words we choose to speak to our patients/clients as practitioners!
There is an elegant study of hotel maids9 that really illustrates this point:
Unsurprisingly hotel maids spend almost every moment of their working lives in physical activity but rather surprisingly most of these women don’t see themselves as physically active – a survey of 84 maids found that 67 percent reported they didn’t exercise. In fact more than one-third of those reported they didn’t get any exercise at all.
Even though all of the women far exceeded recommendations for daily exercise their bodies did not seem to benefit from their activity. When body fat, waist-to-hip ratio, blood pressure, weight and body mass index were measured it was found that all of these indicators matched the maids’ perceived amount of exercise, rather than their actual amount of exercise!
In the study they were divided into two groups –
- Group one – researchers carefully went through each of the tasks they did each day, explaining how many calories those tasks burned. They were informed that the activity already met the definition of an active lifestyle.
- Group two – no information was given at all.
One month later – despite finding no indication that the maids had altered their routines in any way -in the group that had been educated, there was a decrease in weight, waist-to-hip ratio and a 10 percent drop in blood pressure! In other words, returning to our theme of perceived stress, the perception of exercise was more important than actual exercise.
We know also that people’s perception of their health, as reported by self-evaluation surveys, is greater predictor of mortality than actual health as measured objectively. In fact a study of nearly 3,000 people concluded that elderly persons who perceive their health as poor are 6 times more likely to die than those who perceive their health as excellent, regardless of their actual “objectively measured” health status.10
As we guide ourselves and/or our patients on the pathway to good health the more emphasis we can put on the positive impact of our actions the greater the potential good we can do!
We can clearly see the fundamental role emotional management and rest has in managing a disease such as Diabetes and also the role we can play in portraying a positive outlook. We neglect this at our peril as was elucidated some 2,500 years ago when Socrates quotes a Thracian doctor’s criticism of his Greek colleagues: “This is the reason why the cure of so many diseases is unknown to the physicians of Hellas; they are ignorant of the whole. For this is the great error of our day in the treatment of the human body, that physicians separate the mind from the body.”
Dr Morris qualified as a doctor in 1994 and spent six years in hospital medicine – mostly in general adult medicine, but also in paediatrics and Accident and Emergency.
In 2000 David moved into family general practice and was a GP partner for many years. During this time he was also extensively involved in commissioning health care services.
Dr Morris has significant training and experience in complementary therapies such as acupuncture and homeopathy, and ran a primary care based pain clinic for over a decade using acupuncture therapies.
With many thanks to Dr David Morris for this article, if you have any questions regarding the health topics raised in this article then please do get in touch via phone (01684 310099) or e-mail (firstname.lastname@example.org)
Amanda Williams & The Cytoplan Editorial Team: Joseph Forsyth, Clare Daley and Simon Holdcroft
- Perceived stress and incidence of Type 2 diabetes: a 35-year follow-up study of middle-aged Swedish men. Novak M et al.
- Diabetes Care. 2002 Jan;25(1):30-4. Stress management improves long-term glycaemic control in type 2 diabetes. Surwit RS et al.
- The Effects of Relaxation on Glucose Tolerance in Non-insulin-dependent Diabetes. Richard S et al
- Diaphragmatic breathing exercise as a therapeutic intervention for control of oxidative stress in type 2 diabetes mellitus. Hegde SV et al.
- Short Sleep Duration Is Associated with Reduced Leptin, Elevated Ghrelin, and Increased Body Mass Index. Shahrad Taheri et al.
- Sleep loss: a novel risk factor for insulin resistance and Type 2 diabetes. Spiegel k et al
- A single night of partial sleep deprivation induces insulin resistance in multiple metabolic pathways in healthy subjects. Donga E et al.
- Mind-set matters: Exercise and the placebo effect. Crum et al
- Health perceptions and survival: Do global evaluations of health status predict mortality? Idler E et al