Studies of diabetes mellitus: the relation of stressful life situations to the concentration of ketone bodies in the blood of diabetic and non-diabetic humans

Acute psychological stress affects glucose concentrations in patients with type 1 diabetes following food intake but not in the fasting state

OBJECTIVE

To compare the effect of acute psychosocial stress on glucose concentrations in the fasting state and following food intake in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In study 1, 20 patients were exposed to moderate psychosocial stress by means of the Trier Social Stress Test (TSST) in the fasting state. In study 2, the TSST was applied to 20 additional patients 75 min after intake of a standard meal. Glucose concentrations (by continuous glucose monitoring system), blood pressure, and heart rate were monitored on the control day and on the stress testing day.

RESULTS

In both studies, blood pressure increased in response to TSST from 122/77 +/- 14/9 mmHg at baseline to a maximum of 152/93 +/- 21/13 mmHg (P < 0.001), and heart rate increased from 80 +/- 11 to 99 +/- 19 bpm (P < 0.001). In the fasting state (study 1), glucose concentrations remained unchanged during the control day as well as during the stress testing day. In study 2, glucose concentrations were similar on both days before and up to 75 min after the intake of the standard meal. However, a significant delay (of 45 min) in the decrease of glucose concentrations was induced by psychological stress. A two-factor repeated-measures ANOVA revealed a significant difference of glucose concentrations over time (F = 646.65/P < 0.001).

CONCLUSIONS

In the postprandial period, acute psychological stress induced a significantly delayed decrease of glucose concentrations, whereas in the fasting state, no effect on poststress glucose concentrations was observed.

Family stress and metabolic control in diabetes

The common clinical assumption that stress has a deleterious effect on metabolic control in insulin dependent diabetes mellitus (IDDM) has not been confirmed in children and adolescents. This cross sectional study of 43 children and adolescents with IDDM and their families examined the relations between family life stress, family social support, and metabolic control. High family life stress was found to be strongly correlated with HbA1c in the whole group (n = 43) and in children under 12 years (n = 27) when considered separately. Family social support was not found to be directly related to HbA1c, but was found to buffer the effects of family life stress. These findings support the hypotheses that family stress affects metabolic control in IDDM and that good social support buffers these deleterious effects.

Psychological factors affecting physical condition. Endocrine disease literature review

Research exploring the relationship between psychological factors and the onset, exacerbation, and perpetuation of endocrine diseases has focused primarily on three diseases: diabetes mellitus (DM), Graves' disease, and Cushing's disease. There is insufficient evidence to support the position that psychological factors directly affect the onset of DM. Recent laboratory studies suggest that stress is associated with changes in glucose regulation in a subset of diabetic patients and that temperament and coping strategies influence glycemic control in diabetic children and adolescents. Relaxation training may improve blood glucose control in non-insulin-dependent DM patients. There is no good evidence that psychological characteristics affect the development and course of thyroid disorder or Cushing's disease. Recommendations are made for future research.

Testing a theoretical proposition for modeling and role-modeling: basic need and adaptive potential status

The purpose of this research was to test the validity of a propositional statement within the Modeling and Role-Modeling theory and paradigm (Erickson, Tomlin, & Swain, 1988). The Adaptive Potential Assessment Model (APAM) is part of a multidimensional assessment strategy used by nurses to determine ability to mobilize coping resources. This study tested the theoretical proposition that basic need satisfaction and adaptive potential status are directly related. Three study hypotheses were deduced from the identified theoretical proposition. A simple linear relationship between basic need satisfaction and adaptive potential status was not supported. Multidimensional representations of the relationships contained important findings. Understanding more about the relationships between basic need status and adaptive potential will contribute to refining this theory for use in practice.

Reciprocal changes of plasma glucose and ketone bodies in fasted and acutely diabetic rats after CNS stimulation

To assess the effect of chemical stimulation of the central nervous system (CNS) on ketogenesis, we injected neostigmine (5 x 10(-8)mol) into the third cerebral ventricle in normal rats fasted for 48 h and fed rats with diabetes induced by streptozotocin (STZ, 80 mg/kg). The hepatic venous plasma levels of ketone bodies (3-hydroxybutyrate and acetoacetate), free fatty acids (FFA), and glucose were measured for 120 min after the injection of neostigmine under pentobarbital anesthesia. In the normal rats, plasma glucose levels were significantly increased but neither ketone bodies nor FFA were affected by CNS stimulation with neostigmine. In contrast the plasma levels of ketone bodies and FFA were significantly increased in STZ-diabetic rats, while glucose levels remained unchanged. The intravenous infusion of somatostatin (1.0 microgram/kg/min) suppressed the increase in plasma ketone bodies following CNS stimulation in STZ-diabetic rats. These findings suggest that CNS stimulation with neostigmine may accelerate ketogenesis by promoting the lipolysis, which may be induced by glucagon, in fed diabetic rats but not in normal fasted rats.

Elevation of glycosylated hemoglobin in a severe crisis situation--cancer in a close relative

In the present study, 58 relatives of cancer patients (50 women and 8 men, mean age 53) who experienced the grief and tension induced by severe illness in the family were followed. The aim of the study was to examine possible associations between anxiety, depression, and mental exhaustion, on one hand, and glycosylated hemoglobin (HbAlC) level and changes in HbAlC level on the other hand. The relatives were studied approximately once a month during part of the patient's period of illness. On each occasion their psychiatric state was evaluated by means of a standardized observation and interview technique. A blood sample in the nonfasting state was taken for HbAlC assay. The main finding is that a high level of anxiety during the course of a close relative's cancer illness is associated with increasing HbAlC levels (p less than .01).

Psychological factors affecting adherence to diet in male diabetic patients

10 patients with noninsulin-dependent diabetes mellitus were interviewed in depth to identify psychological factors which might influence their adherence to the diet. All patients were evaluated for adherence 6 mo. after an initial interview. Factors which appeared to influence adherence negatively were an established pattern of over-eating, life stress prior to diagnosis of diabetes, depression prior to diagnosis of diabetes, denial of anxiety or depression in reaction to the diagnosis, and denial of future difficulty in adhering to diet. The occurrence of starvation fantasies prior to diagnosis and following institution of the diabetic diet was noted as well as the known similarity of the metabolic state of diabetes to starvation. An intimate relationship between psychology of starvation, onset of diabetes, and adherence to diet is postulatd.

Psychological stress and metabolic control in patients with type I diabetes mellitus

Acute psychological stress is believed to cause disturbances of metabolic control in patients with Type I diabetes. To examine the validity of this assumption, we subjected nine healthy persons (mean [+/- SEM] blood glucose level, 74 +/- 2 mg per deciliter), nine patients with Type I diabetes who had normoglycemia (130 +/- 10 mg per deciliter), and nine diabetic patients with hyperglycemia (444 +/- 17 mg per deciliter) to two acute psychological stresses: mental arithmetic and public speaking. Subjects in the three groups were matched for age, weight, sex, and socioeconomic status. For all subjects, the mean increase in heart rate was 20 beats per minute while they were doing mental arithmetic and 25 beats per minute while they were speaking publicly (P less than 0.001). In all three groups, systolic and diastolic pressure rose markedly, the plasma epinephrine level increased by 50 to 150 pg per milliliter, and the norepinephrine level by 100 to 200 pg per milliliter under both stress conditions (P less than 0.001). The plasma cortisol level rose significantly after public speaking in all groups. Neither stress induced changes in circulating levels of glucose, ketones, free fatty acids, glucagon, or growth hormone. Thus, sudden, short-lived psychological stimuli causing marked cardiovascular responses and moderate elevations in plasma concentrations of catecholamines and cortisol are unlikely to disturb metabolic control in patients with Type I diabetes.

Implications of psychological and family factors in the treatment of diabetes

The authors delineate and discuss in detail those psychological and familial factors that have implications in treatment and in fostering the optimal emotional and physical health of children and adolescents with diabetes mellitus.

Anorexia nervosa and bulimia in diabetics

The evidence suggests that poor diabetic control in adolescence is often associated with omissions of insulin, overeating and other failures in adherence to the treatment regime in the context of some kind of emotional disturbance. Six young patients with diabetes mellitus and an eating disorder (anorexia nervosa or bulimia), who failed to control their diabetes in order to lose weight and to compensate for bulimic episodes, are discussed. Other noteworthy features were their feelings of hopelessness and their unco-operativeness with treatment. Our knowledge of the pathogenesis of anorexia nervosa and of the special problems faced by diabetic adolescents would lead to a prediction that a combination of the two disorders should arise more often than could be accounted for by chance.

The effects of anxiety management training on the control of juvenile diabetes mellitus

The present study was designed to determine whether diabetic control could be improved through the direct psychological management of stress and anxiety. Five poorly controlled female adolescent diabetics ranging in age from 15 to 18 years were used as subjects. All were seen on an outpatient basis over a 6-month period. A single-subject format employing a multiple-baseline design across subjects was used. The independent variable used was a technique known as anxiety management training. Baseline, attention-control, and treatment data were collected on a number of dependent measures. Subjective estimates of anxiety and tension by each subject were gathered on a biweekly basis using the Multifactorial Scale of Anxiety. Diabetic control was assessed daily using the Diastix method and weekly using the 24-hr quantitative glucose method. Data on the five subjects suggested that improved control of stress and anxiety had a positive effect on diabetic regulation. Lower and more stable urine glucose levels using both urine testing methods were found. However, no decreases in the subjects' personal assessment of tension and anxiety were evident.

Stress and immune function in diabetes mellitus

Type I diabetic men were found to have a greater number of stresses, more perceived stress per episode, greater anxiety, poorer immune function, and less metabolic control than Type II diabetic men. Degree of family support and compliance with the medical regimen did not differ. Correlation of perceived stress with immune function and metabolic control showed that Type I had more correlates than Type II, with more perceived stress associated with more depressed immune responses.

The role of "diabetogenic" hormones on carbohydrate and lipid metabolism following oral glucose loading in insulin dependent diabetics: effects of acute hormone administration

To evaluate the relative role of "diabetogenic" hormones as insulin antagonists in severe derangements of diabetic control, glucagon, cortisol, growth hormone and adrenaline were administered by continuous intravenous infusion, separately and in combination, to ketosis-prone insulin-dependent diabetics (n = 11). The amount of insulin required for the assimilation of a 50 g glucose load during the various hormone infusions was determined by means of an automated glucose-controlled insulin infusion system and used as an index of insulin effectiveness. Raising plasma hormone concentrations acutely into the range seen in severe diabetic states (glucagon 517 +/- 70 pg/ml; cortisol 32 +/- 3 micrograms/dl; growth hormone 14 +/- 3 ng/ml) did not alter significantly blood glucose profile and insulin requirement (control 11.3 +/- 1.1 U; glucagon 11.6 +/- 2.0 U; cortisol 11.1 +/- 0.4 U; growth hormone 12.9 +/- 1.4 U), except for adrenaline (plasma level 550 +/- 192 pg/ml), which caused a marked rise in blood glucose levels and a threefold increase in insulin demand (31.1 +/- 3.7 U). Combined infusion of all hormones did not potentiate significantly the latter effect (38.3 +/- 4.7 U). The effectiveness of metabolic control by insulin was assessed by a marked decrease in plasma nonesterified free fatty acids and ketone bodies upon its administration after glucose ingestion in all groups studied. It is concluded that from the hormones investigated within this study adrenaline exerts the strongest diabetogenic action during its short term administration followed by that of growth hormone. Whereas it may well be that over-insulinization of the patients by the glucose controlled insulin infusion system has overcome and disguised the smaller diabetogenic effects of cortisol and glucagon.

The psychophysiologic aspects of stress in juvenile diabetes mellitus

Diabetes Mellitus is the most common endocrine disease found in children, and its reported incidence is increasing. Most investigators now agree that improved diabetic control is effective in decreasing both long and short term complications. The delineation of factors which affect control are, therefore, of importance. Classically, the physician has emphasized insulin dose, presence of infection, diet, and exercise. Emotional factors have long been thought to play a role in diabetes mellitus. The exact nature of this role, however, has been rather elusive and controversial. The authors review this literature, summarize the major viewpoints, and conclude that physiological factors can influence the physiology of the disease. The focus of this paper is the synthesis of recent advances in basic metabolic, endocrinologic, and stress research, relevant to juvenile diabetes, into a psychophysiologic model. The authors discuss future research directions necessary for clarification of the model, as well as its psychological and physiological therapeutic implications.

Psychosocial factors in juvenile diabetes: a review

Studies assessing (1) the influence of psychosocial factors on the onset of juvenile diabetes, (2) the influence of psychosocial factors on the course of this disease, and (3) the influence of diabetes on the psychosocial development of the child are reviewed. Directions for future research are suggested.

Interrelationships of blood sugar and ketones in insulin-treated diabetics

A survey of ketonuria in insulin-treated diabetics showed that its significance might vary according to the time of day at which the test was performed. Some of the patients had uncontrolled diabetes in the early morning, when severe hyperglycaemia and hyperketonaemia occurred together, while later during the same day or night an episode of hypoglycaemia caused hyperketonaemia, indicating that too much insulin had been given. Correct assessment of the significance of ketonuria is obviously important, because some patients would probably require a decrease rather than an increase of insulin dosage. Ketonuria does not necessarily indicate impending ketoacidosis.