Diabetes

The key to living well with diabetes is to avoid problems which arise from prolonged hyperglycemia (elevated blood glucose levels) or repeated episodes of hypoglycemia (low blood glucose levels). In order to achieve a balance, individuals with diabetes must regulate their behaviour on a daily basis.

Diabetes is a psychologically and behaviourally demanding disease, and psychosocial factors are relevant to nearly all aspects of its management. Diabetes presents a significant challenge and stress for diabetics as well as their family and friends.

Psychologists can play a valuable role in helping people live well with diabetes. Psychologists are well trained in behaviour change interventions. They understand the problems in diabetes self-care, and can help the individual to overcome the difficulties and to change their behaviour to improve well-being.

A variety of psychological and educational interventions have been shown to enhance psychological adjustment to diabetes. Effective interventions include psychosocial support and reinforcement, coping skills training, stress-management and relaxation skills training, cognitive-behaviour therapy, and family behaviour therapy. Approaches that increase patient participation in decision-making regarding care and education have been shown to be more effective than a "do as I say" approach in enhancing psychological adjustment to diabetes and potentially preventing psychological distress.

The Effects of Stress and Negative Emotions
on Diabetes

Stress and associated negative emotions are an important risk factor in a number of degenerative diseases that most often develop in adulthood, especially cardiovascular diseases and diabetes. There is good evidence that stress not only increases glucose levels in persons with diabetes but can actually increase the risk of developing diabetes—especially Type 2 diabetes.

For example, a number of recently published studies have reported that job-related stress and emotional burn-out are significant risk factors for the development of Type 2 diabetes in apparently healthy men and women. In many cases doubling or even tripling the risk over time periods of 3-5 years, even after accounting for the effects of age, gender, obesity, smoking, physical activity, and leisure time. Other studies have shown that stress can increase insulin resistance and raise blood glucose levels in persons with diabetes.

To understand how stress can both increase the risk of developing diabetes as well as aggravate the disease in those with diabetes, we must first learn a little about what stress is and how the body responds to stressors.

What is stress?

“Stress” may be defined as the body’s natural response to anything that actually threatens— or that we think will threaten— our well-being. Such real or perceived threats are called “stressors”.

Stressors can be physical, like confronting a dangerous animal or angry person, sustaining injury or illness, or too much heat, cold or noise. Or they can be psychological, like problems in your personal relationships, job, health or finances, or worrying about possible physical dangers.

Our body responds to both physical and psychological stressors in the same way— by preparing us to run away from the danger or stand and fight for our lives. Commonly called the “fight-or-flight response”, this response to threat is a basic survival mechanism that is “hard-wired” in us by evolution.

How does stress affect diabetes?

One important purpose of the stress response is to instantly increase the amount of energy available to the body and brain. This is accomplished by releasing glucose into the bloodstream from its storage in the fat cells while simultaneously shutting down the production of insulin in the pancreas. This leads to temporary hyperglycemia— which is OK in the short-run, during an emergency, when we require immediate energy for a physical response such as running away from or facing up to danger. In such situations the threat is usually short-lived, we rapidly burn-up the extra glucose through our physical exertions, and our stress response shuts off after the danger has passed. Once the danger has passed our body soon returns to a more neutral and balanced state.

While the fight-or-flight stress response works pretty well for us when facing short-term physical danger, it does not work nearly as well for the psychosocial stressors that we mostly face in our modern lives. Most of us today do not face frequent physical dangers, instead we are primarily stressed by annoying little hassles and time-pressures and complex psychosocial problems involving our life roles and relationships at home and work. Moreover as human beings, we have the capacity to keep stressors alive by thinking about them and to stress ourselves by worrying about possible dangers.

For all too many of us, modern life triggers the stress response all too frequently throughout the day and the types of problems we experience, together with rumination and worry, cause us to become chronically stressed. Our stress response gets turned on but never gets completely shut down.

It is this chronic state of being stressed and the associated negative emotions of anger and hostility, anxiety and fear, helplessness and hopelessness, etc. that cause neurotransmitter and hormonal imbalances within our bodies that lead to the development of diseases such as diabetes.

Over the years, stress results in frequent episodes of hyperglycemia and, as it becomes more chronic, increasing insulin resistance in otherwise healthy persons. And, when combined with insufficient exercise, a high fat and high glycemic diet, and increasing body weight, chronic stress almost ensures the eventual development of diabetes and cardiovascular disease.

But for persons with diabetes stress can be an even greater problem. As we know, the key to managing diabetes is to keep your blood glucose levels within a relatively narrow range throughout the day. This involves the careful dynamic balancing of food intake, activity, and insulin— either the insulin that your body still produces in the case of Type 2 diabetes, or the insulin that you must inject in the case of Type 1 diabetes. Stress can clearly upset this delicate balance and result in higher than expected glucose levels. It also makes it very difficult to properly adjust blood glucose with added insulin because during the stress response your resistance to insulin is increased and it takes a greater amount of insulin to move glucose out of the blood and back into the cells.

How can persons with diabetes test their response to stress?

A relatively easy and effective way of learning how stress affects your glucose levels and diabetes management is to add an estimate of your stress level to your blood glucose testing. Simply keep a stress/blood glucose diary and whenever you test your blood glucose during the day write the time of day and the test result into your diary together with a number from 0 to 10 that represents your average feeling of being stressed over the previous hour— with 0 equal to no stress whatsoever and 10 representing the highest level of stress that you have ever experienced in your life. Keep track of your stress and blood glucose levels over at least 30-45 days and then graph the data to examine the relationship.

What are the signs of stress?

While the physiological stress response is pretty much the same for everyone, each person experiences their stress differently in psychological terms. For example, some people become quite energized, agitated, and irritable. Some become apathetic, fatigued, and depressed. Others become ruminative, nervous, and anxious. Often stress results in changes in eating and sleeping habits as well as a loss of sexual desire and energy. Stress is also frequently associated with the development of muscle tension, generalized aches and pains, and headaches. But the best indicator that you are experiencing stress is your emotional experience. Stress causes negative emotions and chronic stress is invariably associated with chronically negative emotions.

How can you reduce stress?

First and foremost, do not just accept stress and live with it. Become aware of stress in your life and how it makes you feel bad. Recognize those bad feelings as a sign to do something to reduce your stress. Apply the following strategies to manage your stress…

Make a list of the things in your daily life that stress you and then make practical plans to avoid or change those that you can or make an effort to change the way that you think about these stressors so they will not be as stressful to you. For example, if the traffic going to work stresses you, try leaving for work earlier or later or taking a different route. If your job duties are too stressful, talk to your boss about how things might be improved. If you are at odds with a friend or relative and constantly thinking badly of them, make an effort to focus your thoughts on their good qualities and make the first move to patch things up.

Learn to say no first. Don’t feel that you have to do everything for everybody. Know that is OK to say “no”.

Choose your battles in life. Be flexible. You do not have to react to every situation. Ask yourself if it is really worth the energy.

Be prepared. Plan ahead for possible crises—not the same as simply worrying about possible crises. Plan ahead for the support you will need to get through them.

Take things one day at a time. Don’t become overwhelmed. Live one day at a time.

Some sources of stress are never going to go away, no matter what you do. For these stressors, you can only change how you perceive them, or how you respond to them, or compensate for the stress they give you by reducing stress elsewhere.

You can also do things to fight the effects of stress on your body…

Go for a walk. Regular moderate exercise works wonders to relieve stress and it also helps control your blood sugar levels.

Take some time out every day to enjoy yourself. Try a hobby or craft. Make sure that you spend at least one hour a day engaging in an activity that you truly enjoy and gives you pleasure.

Take breaks during the day to relax. Practice slow, diaphragmic breathing (breathing from the belly using the diaphragm) at approximately 6 breaths per minute (breathe in for about 4 seconds and out for about 6 seconds) while simultaneously thinking of a person, place or thing that you truly appreciate. Do this breathing exercise at least 2-3 times a day for a minimum of 10 minutes.

Become aware of your different stress levels through the day. Make it a habit to self-monitor your feelings of being stressed and, using a 0 to 10 scale, regularly rate your current level of stress. Whenever your stress rating is over 5, do something to reduce it. For example, take a few moments to think of something pleasant, breath slowly and deeply, and let go of any tension in your muscles.

If you find yourself becoming depressed or chronically anxious or find that you are experiencing a great deal of negative emotions that you cannot successfully alleviate on your own, seek professional help. Talk with your primary care physician. Consider asking your physician for a referral to a psychologist who can help you better manage your stress and your negative feelings.

Chronic Work-Related Stress is Associated with the Development of Type 2 Diabetes.

The recently published results of a large Swedish health survey by Dr. Emilie Agardh at the Karolinska Institute revealed that work stress and low emotional support tripled the risk of developing type 2 diabetes in healthy women over a 3-7 year time frame. In this study the link between work-related stress and diabetes was only statistically significant for women. There was a trend towards increased risk for men that failed to reach statistical significance.

However, a similar British study of over 10,000 people over 14 years by Dr. Tarani Chandola found that men with high levels of chronic work stress were nearly twice as likely to develop metaic syndrome than men with low levels of chronic work stress. Metabolic syndrome is marked by the development of abdomenal obesity, insulin resistance, high blood pressure and high cholesterol. Metabolic syndrome greatly increases the risk of becoming diabetic.

Stress Management Improves Long-Term Glycemic Control in Type 2 Diabetes

R.S. Surwit, M.A.L. van Tilburg, N. Zucker, C.C. McCaskill,
P. Parekh, M.N. Feinglos, C.L. Edwards, P. Williams, & J.D. Lane

Duke University Medical Center, Durhan, NC

Objective: There is conflicting evidence regarding the utility of stress management training in the treatment of diabetes. The few studies that have shown a therapeutic effect of stress management have used time-intensive individual therapy. Unfortunately, widespread use of such interventions is not practical. The aim of the present investigation is to determine whether a cost-effective, group-based stress management training program can improve glucose metabolism in patients with type 2 diabetes and to determine whether a particular subset of patients is more likely to get positive results.

Research Design & Methods: Patients with type 2 diabetes were randomized to undergo a five-session group diabetes education program with or without stress management training. Participants (n = 108) were followed for 1 year, during which HbA1c tests and questionnaires assessing perceived stress, anxiety, and psychological health were administered at regular intervals to evaluate treatment effects.

Results: Stress management training was associated with a small (0.5%) but significant reduction in HbA1c. Compliance with the treatment regimen decreased over time but was similar to that seen in patients receiving stress management for other reasons in the clinic. Trait anxiety (a measure of stable individual differences in anxiety proneness) did not predict response to treatment, showing that highly anxious patients did not derive more benefit from training.

Conclusions: The current results indicate that a cost-effective, group stress management program in a “real world” setting can result in clinically significant benefits for patients with type 2 diabetes.

Published In: Diabetes Care, 2002; Vol. 25, pp. 30-34.

Diabetes and Depression are Linked

Dr. Horst H. Mueller, CRHSPP, FBCIA-EEG
Registered Psychologist

Although depression is rarely listed as a complication of diabetes, it can be one of the most common and dangerous.

Several studies suggest the incidence of depression in diabetics to be 2 to 3 times higher than in non-diabetics; with life-time risk of a serious depressive episode ranging from 15 to 32 percent. Both the incidence and life-time risk for depression are greater for diabetic females than males by approximately 2:1. The odds of depression are similar in type 1 and type 2 diabetes and it is likely that up to a third of all diabetics actually have depression at any given time.

The chances of becoming depressed increase as diabetes complications worsen. Studies have reported that diabetics with good blood glucose control are less likely to be depressed than those with poor glycemic control. On the other hand, effective treatment of depression has been shown to improve glycemic control in diabetics.

Numerous research studies have also found that depression is associated with a variety of diabetes complications such as diabetic retinopathy, nephropathy, neuropathy, macro vascular complications, and sexual dysfunction.

Not only does depression worsen diabetes but the course of depression in diabetics tends to be more severe, with more frequent recurrences, than in the general population.

Depression has not only been shown to be a common complication of diabetes in general, but has also been implicated as a significant risk factor in the development of type 2 or “adult onset” diabetes. Compared to non-diabetics, persons with diabetes are far more likely to have experienced a major depressive episode within six months prior to being diagnosed. In one study about 84% of diabetics reported a higher rate of earlier depressive episodes than those in the non-diabetic control group. Another study reported depression to be associated with a two-fold increase in risk for type 2 diabetes. While the data to date does not prove a causal link, it appears that depression more frequently precedes the onset of diabetes, than vice versa.

One plausible explanation involves the action of the hormone cortisol, which is released into the bloodstream during stress. Cortisol is known to increase the release of glucose into the bloodstream while simultaneously interfering with insulin production resulting in insulin resistance. Similarly, chronically high levels of cortisol are toxic to certain parts of the brain (i.e., hippocampus) that play an important role in moderating our moods, especially depression. Through these mechanisms, high levels of circulating cortisol resulting from chronic stress may trigger both type 2 diabetes and depression.

To further complicate matters, once a person becomes diabetic, the metabolic effects of diabetes on the brain may also result in depression. As well, diabetes is a very challenging illness, and simply coping with the disease and its complications is stressful and may lead to depression.

Regardless of what may be responsible for the association between depression and diabetes, when both are present, management of either condition becomes more difficult and complex and it becomes very important that both be adequately treated.

There are many symptoms that might indicate depression (see box), some of which— e.g., fatigue, weight loss— may actually be caused by diabetes, but a sad mood and significant loss of interest or pleasure are key symptoms of depression that cannot be directly attributed to diabetes and should not be ignored. If you suspect that you are depressed it is essential that you do not ignore your suspicions but instead seek a professional evaluation. The most important starting point in managing the problem is an early and accurate diagnosis.

Symptoms of Depression

· Persistent feelings of sadness, anxiety, or “emptiness

· Feelings of hopelessness, pessimism

· Feelings of guilt, worthlessness, helplessness

· Apathy or loss of interest and pleasure in things that were once enjoyed, including sex

· Decreased physical and mental energy, feeling “slowed down”

· Difficulty concentrating, remembering, making decisions

· Insomnia, early-morning awakening, or over-sleeping

· Changes in appetite and/or weight changes

· Thoughts of death or suicide or suicide attempts

· Restlessness or irritability

If five or more of these symptoms are present every day for at least two weeks and interfere with routine daily activities such as work, self-care, childcare, or social life, see a primary care physician, psychiatrist or psychologist and ask to be evaluated for depression.

In recent years there have been major advances in the treatment of depression. There are specific medications and specific psychotherapy techniques that have been proven to help depression. As a matter of fact, the current research supports a treatment approach that combines antidepressant medications with a form of psychotherapy called Cognitive-Behavioral Therapy as being the most effective in terms of both alleviating depression and preventing recurrence.

Antidepressant medications focus on changing the balance of neurotransmitters in certain areas of the brain to alleviate many of the symptoms of depression. There is a much wider variety of antidepressant medications available today than were available only 15-20 years ago. With the increase in medication choices, it is now easier for your physician to prescribe a medication that will effectively treat your depression with minimal side-effects and fewer problematic interactions with your diabetes and other medications. However, it is still important to understand that not every one responds the same to a given medication and, therefore, your physician will likely need to adjust the dose from time to time and may even need to try more than one medication before the right combination is found.

Cognitive-Behavioral Therapy focuses on helping the individual identify thought patterns and behaviors associated with depressive, helpless and hopeless outlook. Often such thought and behavior patterns are based on mistaken assumptions about self and others. The psychologist helps the client become aware of and monitor their dysfunctional patterns of thought and behavior and then develop strategies to replace them with more effective and positive ways of thinking and behaving. Cognitive-Behavioral Therapy can also be very helpful to non-depressed diabetics who are having problems with their diabetic management, especially when those problems involve difficulty in consistently following through with the many things necessary to ensure good blood sugar management and/or are related to high levels of stress.

If you are being treated for diabetes and are experiencing symptoms of depression, talk with physician about the possibly of obtaining both medical and psychological treatment. Ask about a referral to a registered psychologist who is experienced in Cognitive-Behavioral Therapy.

Remember, good diabetes management is not only about what you eat but also what is eating you.

Dr. Horst H. Mueller, is a registered psychologist with an Edmonton-based practice in clinical and health psychology located within the Miramas Health Clinic in the Whitemud Crossing. His practice combines schema-based and cognitive-behavioral psychotherapies with applied psychophysiology and biofeedback therapies in the treatment of chronic psychological and psychosomatic illness as well as physical medical conditions in which psychological factors play an important role.

Dr. Mueller is interviewed on psychological factors in diabetes on Diabetes Compass Radio. To listen to these two interviews click on the links below...

Diabetes and Stress
www.diabetescompass.com/showinfo.php?showid=21

Diabetes and Your Emotions
www.diabetescompass.com/showinfo.php?showid=29

The Connections Between Stress,
Diabetes and Obesity

Dr. Horst H. Mueller, CRHSPP, FBCIA-EEG
Registered Psychologist

Stress is woven into the fabric of our lives. The physical stress response was hardwired by evolution so that when there is an immediate threat to life or limb, our bodies prepare us in a split-second to defend ourselves by fighting or to escape by running away— the fight or flight response. In situations where something comes out of the bushes and wants to eat us, the stress response is an almost perfect survival mechanism. Modern times, however, do not offer us many threats that require an immediate physical response. Today, getting the kids off to school on time, arguing with your spouse about household finances, heavy traffic, falling stock prices, down-sizing in the workplace and any number of everyday hassles trigger the stress response in us. Moreover, many of these non-physical threats tend to linger in our minds long after the initiating event has passed. Unlike an attack by a ravenous lion which is over, one way or another quite quickly, we keep the psychosocial stressors alive in our minds and relive them over and over again because they are not simply solved by running away or fighting to resolution.

Stress can affect virtually any part of the body and produces physical, mental and emotional symptoms including allergies, environmental sensitivity, dizziness, headache, heart palpitations, impaired coordination, impaired immunity, reproductive dysfunction, carbohydrate cravings and weight gain.

Under stress, the body releases adrenaline and the stress hormone cortisol from the adrenal cortex. In turn, adrenaline speeds up the heart and increases the speed and pressure of blood carrying oxygen and energy (in the form of glucose and fatty acids) to the muscles and brain to help us run or fight and cortisol stimulates the release of glucose into the bloodstream from storage in the fat cells. This increase in glucose in the blood causes a rise in insulin, a fat-storage hormone that signals the fat cells (especially those in the abdomen) to store glucose and fatty acids from the blood as fat. This stress response system is exquisitely well-designed for situations in which life or limb are threatened, the threat is relatively short-lived, and we handle the stress by running away or defending ourselves.

But as stated earlier, most stressors in modern life do not require us to run or fight. This means that all the glucose and fatty acids released into the blood in response to stress are not burned up by physical activity and remain clogging up the bloodstream doing damage to the body. Worse, because modern stressors do not just end but tend to linger on, the finely-tuned balance between eating, metabolism and physical activity becomes disrupted.

Chronic stress results in increased absolute levels of both cortisol and insulin. Excessive cortisol stimulates high blood sugar levels which, in turn, triggers excess secretion of insulin which signals the body to store fat in the abdomen. As the fat cells in the abdomen become filled up, it takes ever more insulin to force more glucose out of the bloodstream and into storage. This is insulin resistance.

Moreover, because carbohydrates stimulate the production of serotonin, the brain’s mood-calming neurotransmitter, chronic stress also drives carbohydrate cravings which result in our eating too much carbohydrate-rich and sugary comfort foods.

With the persistence of chronic stress, we eventually have the situation where we are eating excess amounts of food, which both increase our blood sugar levels and the demand to convert these excess blood sugars into stored fat. But the excess cortisol fights the excess insulin and we end up with both weight gain and increasing insulin resistance. As our fat cells continue to be filled up, they become ever more resistant to insulin’s message to store more glucose as fat. Eventually our fat cells are completely filled up and no amount of insulin is enough to move the increased blood sugars that follow eating out of the blood and into the the fat tissues. We have become diabetic.

Unlike Type I diabetes where the panceas simply does not produce enough insulin to meet the body’s glucose-regulation demands, in Type II diabetes, the body produces lots and lots of insulin but can no longer respond to it.

Type II diabetes accounts for over 90% of all diabetics and 80% of Type II diabetics are obese. Worse, the incidence of both obesity and Type II diabetes is rapidly increasing in our modern population because of the factors of chronic stress, over eating, and under exercising. Chronic stress and reduced physical exercise significantly increase the risks of obesity which, in turn, greatly increases the risk for Type II diabetes.

Stress management is important for the good health of all Canadians— recent polls suggest that 28% of Edmontonians view themselves as highly stressed—but for those with diabetes it is especially beneficial.

Research has shown that, separate from changes in diet and exercise, managing stress can significantly improve persons control of their diabetes. Moreover, stress management techniques are relatively simple, quick to learn, and have been shown to work for multiple conditions, including coronary syndromes. There are many self-help books and other commercially available materials about stress management from which people can learn the necessary techniques.

Stress and Personality

You have some control over your reaction to stress. You can learn to relax and reverse the body's hormonal response to stress. And, of course, you may be able to change your life to relieve sources of stress.

Something else that affects people's responses to stress is coping style. Coping style is how a person deals with stress. For example, some people have a problem-solving attitude. They say to themselves, "What can I do about this problem?" They try to change their situation to get rid of the stress.

Other people talk themselves into accepting the problem as okay. They say to themselves, "This problem really isn't so bad after all."

These two methods of coping are usually helpful. People who use them tend to have less blood glucose elevation in response to mental stress.

You can get help in learning how to better cope with stress by seeing a psychologist for cognitive-behavioural stress management

Learning to Relax

There are many ways to help yourself relax:

• Breathing exercises. Sit or lie down and uncross your legs and arms. Take in a deep breath. Then push out as much air as you can. Breathe in and out again, this time relaxing your muscles on purpose while breathing out. Keep breathing and relaxing for 5 to 20 minutes at a time. Do the breathing exercises at least once a day.

• Progressive relaxation therapy. In this technique, which you can learn in a clinic or from an audio tape, you tense muscles, then relax them.

• Biofeedback therapy. See a psychologist and learn to better control your body’s physiological response to stress through biofeedback training.

• Exercise. Another way to relax your body is by moving it through a wide range of motion. Three ways to loosen up through movement are circling, stretching, and shaking parts of your body. To make this exercise more fun, move with music.

• Replace bad thoughts with good ones. Each time you notice a bad thought, purposefully think of something that makes you happy or proud. Or memorize a poem, prayer, or quote and use it to replace a bad thought. Or replace negative thoughts with appreciative thinking— focus your mind on a person, place or thing that you truly appreciate and think only of how much you appreciate it.

Whatever method you choose to relax, practice it. Just as it takes weeks or months of practice to learn a new sport, it takes practice to learn relaxation.

Other Ways to Reduce Mental Stress

You may be able to get rid of some stresses of life. If traffic upsets you, for example, maybe you can find a new route to work or leave home early enough to miss the traffic jams. If your job drives you crazy, apply for a transfer if you can, or possibly discuss with your boss how to improve things. As a last resort, you can look for another job. If you are at odds with a friend or relative, you can make the first move to patch things up. For such problems, feeling stressed may be a sign that changes are called for.

Some sources of stress are never going to go away, no matter what you do. Having diabetes is one of those. Still, there are ways to reduce the stresses of living with diabetes. Support groups can help. Knowing other people in the same situation helps you feel less alone. You can also learn other people's hints for coping with problems. Making friends in a support group can lighten the burden of diabetes-related stresses.

There are other ways to fight stress as well. Sometimes adding positive things to your life can help. You can start an exercise program or join a sports team. You can take dance lessons or join a dancing club. You can start a new hobby or learn a new craft. You can volunteer at a hospital or charity. Learn yoga or tai chi.

Dealing directly with diabetes-related stress can also help. Think about the aspects of life with diabetes that are the most stressful for you. It might be taking your medication, or checking your blood glucose levels regularly, or exercising, or eating as you should.

You can get help with any of these issues. Ask a member of your diabetes team for a referral. Sometimes stress can be so severe that you feel overwhelmed. Then, counseling or psychotherapy might help. Talking with a therapist may help you come to grips with your problems. You may learn new ways of coping or new ways of changing your behaviour.

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Biofeedback-Assisted Relaxation
in Type 2 Diabetes

R.A. McGinnis, A. McGrady, S.A. Cox, and K.A. Grower-Dowling
Department of Psychiatry, Medical University of Ohio, Toledo, Ohio

Objective: The objective of this randomized controlled study was to determine the effects of biofeedback and relaxation on blood glucose and HbA1c (A1C) in patients with type 2 diabetes.

Research Design and Methods: Patients with type 2 diabetes were randomized to either 10 sessions of biofeedback (EMG and TEMP) and relaxation or 3 sessions of education. All sessions were individual. A total of 39 participants were entered, and 30 completed the 3-month protocol. Average blood glucose and A1C, forehead muscle tension (EMG) and peripheral skin temperature (TEMP) were assessed, and inventories measuring depression, and anxiety were administered pre-randomization and after completion of treatment/control.

Results: Biofeedback and relaxation were associated with significant decreases in average blood glucose, A1C, and muscle tension compared with the control group. At 3-month follow-up, the treatment group continued to demonstrate lower blood glucose and A1C. Both groups decreased scores on the depression and anxiety inventories. Patients with depression had higher blood glucose levels and tended to drop out of the study.

Conclusions: This study supports the use of biofeedback and relaxation in patients with type 2 diabetes for up to 3 months after treatment. Further research is necessary to determine the long-term effects of biofeedback and the effects of mood on patients' responses to treatment.

Published In: Diabetes Care, 2005, Vol. 28, Issue 10, pp. 2145-2149.