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The Well Being Way Stress Management Program Summary

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Stress management

Stress is a primary predictor of relapse and overeating, and stress management training is an important part of most programmes. Stress management involves teaching people with diabetes methods for reducing stress and tension, including diaphragmatic breathing, muscle relaxation or meditation (see page 47 above). In addition, stress inoculation involves having people visualise stressful situations while practising their relaxation skills, therefore allowing them to practise managing stressors in a safe environment and improving their confidence in coping with stressful situations. These techniques are designed to reduce tension and associated changes that occur in your body in response to stressors and have been found to be very effective for numerous health-related problems, including diabetes.

Other key quality of life factors

I Stress management A study described in Diabetes Care in January 2002 showed that lowering stress lowers blood glucose. Patients were divided into two groups, one of which received diabetes education alone and the other diabetes education plus five sessions of stress management. The latter group showed significant improvement in diabetic control versus the former group, who received only diabetes education.

Effective Treatment For Depression In Diabetes

Cognitive-behavioural therapy (CBT) is based on the observation that depressed people tend to think in negative, stereotypical ways ('Nobody likes me I'm a failure' 'I'll never be able to control by diabetes'). CBT involves a structured programme of cognitive modification or reframing and behavioural activation, which I have already described. Negative, self-defeating thoughts and actions are identified and efforts are made to replace them with more accurate and constructive thoughts and behaviours41. Preliminary findings from a controlled study suggest that CBT is robustly effective in the treatment of depression in diabetes65 Both IPT and CBT help patients build skills for coping better with stressful life circumstances. This may provide these patients some advantage over treatment with antidepres-sant medication in terms of more lasting relief from depression, a significant advantage given the recurrent feature of depression in diabetes3.

How does stress affect the body

Stress is a natural survival response. It occurs within the body when you feel threatened by thoughts or external stressors. When you are in a stressful situation, your circulatory system speeds up and blood is pushed rapidly towards different parts ofthe body, particularly those organs and systems necessary to protect you and this raises your blood pressure. Because the blood supply has been diverted, the supply to the digestive system is usually reduced as well, making the process of digestion slower and less effective. Stress also constricts the blood vessels, increases heart rate, and produces other physiological manifestations, all instantaneously

Management Of Pregnancy In Diabetes

For every parent, delivery is a stressful event. In the case of a mother with diabetes, stress levels may be increased in view of the risk of obstetric complications related to macrosomia and pregnancy-induced hypertension (pre-eclampsia). Clinical studies indeed suggest a higher occurrence of premature labour and preterm delivery in diabetic pregnancies23. Little is known about how diabetic pregnancy, in both type 1 and gestational diabetes, affects the development of the maternal-infant relationship. There is some research to suggest that children from diabetic mothers are at increased risk for a variety of behavioural disturbances, partly related to the children's obesity24.

Increased strength and flexibility

Regular exercise can help you to look and feel better, physically and emotionally. It can help you lose weight and body fat and increase muscle tone and strength. For women, exercise, especially weight-bearing activities, can help preserve bone mass and prevent osteoporosis. It is a good way to handle stress as well.

Oral diabetes medications or oral hyperglycemic medications

Stress hormones or counter-regulatory hormones Hormones released during stressful situations, such as an illness or infection. These hormones include glucagon, epinephrine (adrenaline), norepinephrine, cortisol, and growth hormone. They cause the liver to release glucose and the cells to release fatty acids for extra energy. If there's not enough insulin present in the body, these extra fuels can build up and lead to hyper-glycemia and ketoacidosis.

Treatment for Comorbid Depression and Diabetes

Cognitive behavioral treatment has been shown useful in the treatment of depression in persons with diabetes however, data is scant. This therapeutic approach modifies dysfunctional thinking, reduces negative emotions, trains stress reduction, and provides skill building in areas of deficit. Improvements in mood, quality of life, and coping were demonstrated in the only large-scale randomized clinical trial to date in DM2 adults (45). However, other data from less statistically robust studies exists. Cognitive behavioral therapy has shown effects through improved glycemic control and quality of life (15,46), and evidence suggests that CBT techniques may prove beneficial in improving compliance to diabetes regimen (45).

Relaxation Training Can Improve Glucose Tolerance And Reduce Longterm Hyperglycaemia

A variety of studies over the past two decades support the notion that improving stress management or coping skills can improve self-care, metabolic outcomes and quality of life. For example, several studies of people with type 2 diabetes generally report improved glucose tolerance and reduced long-term hyperglycaemia following biofeedback-assisted relaxation training (BART) - 0. Evidence for the effectiveness of BART in people with type 1 diabetes is less conclusive. While several studies11,12 reported positive effects of BART and related treatments for those with type 1 diabetes, others13-15 found no such benefits. Surwit and Feinglos15 suggest that sympathetic nervous system activity may be altered only in those with type 2 diabetes, making these individuals more sensitive than those with Marrero and colleagues19 found that adolescents who participated in a series of sessions designed to improve diabetes-related coping skills were less depressed, and also tended to have higher...

Stress And Blood Glucose Control

Evidence from animal models also suggests a role for stress in the onset of type 2 diabetes (45). Ineffective coping (e.g., avoidance, denial, detachment, anger) has been shown to be associated with poorer metabolic control in diabetes and adaptive coping (e.g., active problem solving and ability to obtain social support) with a stress-buffering role (46), highlighting the role of patient perceptions of stressful events. It is unclear whether relaxation training (e.g., biofeedback) produces glycemic benefits in type 2 diabetes (47). Generally, there is a paucity of studies on stress in type 2 diabetes.

The Diabetic Surgical Population

It is estimated that 6.0 million patients develop significant hyperglycemia each year while in the hospital. Many of these patients will have a prior diagnosis of type 1, type 2, gestational, or secondary diabetes. Approximately half of the hyperglycemic patients will have previously undiagnosed diabetes and will require insulin or oral hypoglycemic therapy following discharge from the hospital (27-29). A significant number of non-diabetic patients will develop hyperglycemia due to the metabolic effects of anesthesia, tissue trauma, pain, systemic illness, and infection (1-3). Although insulin is often required during the stressful event, medication is often not required following hospital discharge. The number of surgical patients with diabetes and impaired glucose tolerance (IGT) is expected to increase over the next 15 years, due to the aging baby-boom population, the sedentary lifestyle of the US population, and the increasing incidence of obesity (26,29).

How can you cope with stress

Since stress can affect the body and mind in so many ways, stress management is a very important part of any programme for coping with diabetes. It is clear that stress can affect certain aspects ofdiabetes, including blood sugar levels. Importantly, you can learn effective strategies that will help you to deal with it. Obviously smoking, alcohol abuse, the use of inappropriate drugs, and overeating are all common but poor coping strategies. True, these activities will distract you and perhaps delay the effects of the stress, but they can also hurt you and prevent you from coping with stress in a constructive way. So, what should you do Relaxation techniques and regular exercise can be helpful parts of stressmanagement programmes. Also, by thinking more appropriate and positive thoughts, you can go a long way towards reducing stress as well. But be realistic and remember that while stress can be managed and controlled, it cannot be eliminated. Your focus, then, should be on using the...

What causes stress in diabetes

Diabetes can cause stress in a number of different ways. You may feel under a great deal of pressure to maintain 'perfect' control of your diabetes. You may feel stressed because the side-effects of diabetes are interfering with your sex life and relationships. Problems with your treatment or adjustments to dietary and lifestyle changes can cause stress. Fears of short- or long-term complications are also common stressors for people with diabetes, and indeed worries about being able to fulfil responsibilities may also provoke a stress response. We all have a unique way ofresponding and your particular pattern of response to stress will depend on a number of things. Your upbringing, your self-esteem, your beliefs about yourself and the world, the way in which you guide yourself in your thoughts and actions - all of these things help to determine your stress response. The degree to which you feel in control ofyour life also plays an important role in this response, as does the way you...

What Else Might Help

Finding some means of stress reduction or stress management is important as well. Stress raises levels of cortisol, which in turn boosts insulin levels contributing to an increased risk of both abdominal obesity and heart disease. Removing yourself from the stress, even temporarily, can have an extraordinary effect. Consider a daily walk (which also lowers glucose and insulin levels), meditation, a hobby, recreational reading, or sightseeing as stress-reducing activities.

Behavioural Therapy

Behavioural treatments for obesity originated in the 1960s and were founded on the concept that altering behaviours associated with eating and activity could be central to weight loss. Specific strategies include self-monitoring of both eating habits and physical activity, stress management, stimulus control, problem solving, contingency management, cognitive restructuring and social support. Treatments employing cognitive behavioural therapy (CBT) generally achieve levels of between 5-10 weight loss. A notable fact with regard to studies which have investigated CBT as a treatment strategy is that drop-out rates are very low. Over 80 of subjects who enter behavioural treatments complete the programme and are available for follow-up (80). It is recognised that CBT may produce the best results when combined with other treatments (81).

Lifestyle trials

The CDDP was developed in Minneapolis, Minnesota, USA to determine if a low intensity community-based intervention could alter the natural history of insulin resistance, IGT and type 2 diabetes67. Subjects were identified using a simple screening interview, then randomized to a nutrition, physical activity and stress management intervention group or control, as described in Table 6.3. After two years, this low intensity intervention has reported no differences in diabetes incidence between intervention and control groups, however, four-year follow-up is currently being completed, with results to be reported in the near future. The other lifestyle studies underway differ from this community-based low intensity approach by including higher risk subjects and using more intensive interventions.

Handling Stress

One way to deal with a stressor is to eliminate it. If we can't eliminate the stress, we need to find a way to deal with it. This is called coping. Everyone needs a variety of coping skills to use in different situations. Each person deals with stress in his or her own way. We usually behave in ways that are familiar to us. Some of these strategies work and some leave us feeling tense, tired, angry, or sick. Some, such as smoking, drinking too much, and drug abuse, cause other problems. Other techniques and ways of dealing with stress can help us to feel more in control, relaxed, and less tense after a stressful event. To determine if a strategy is effective, ask yourself, Did it work Did I feel better both temporarily and later Is this an effective strategy to use in the future There are three important factors in coping having enough information, feeling in control, and having the support of others. Some of the following stress management strategies might work for you

Bgatearly Studies

While some aspects of BGAT have remained consistent over consecutive revisions (e.g. Awareness Diaries, weekly meetings), the intervention in its current form bears little resemblance to early versions. In the original version37 (Study I) there was no structured manual or BG Awareness Diary. Patients recorded their symptoms, BG estimates, and actual BG measurements on paper, then reviewed and discussed these diaries in meetings held for 10 consecutive weeks. The goals for these meetings included identifying reliable and misleading symptom cues, as well as systematic biases in BG estimation (e.g. underestimating hyperglycaemia). A control group met for 10 weekly classes in stress management training. Pre-treatment and post-treatment accuracy of BG estimation was assessed in both an inpatient setting, where glucose levels were manipulated34, and at home. After BGAT, both hospital and home estimates showed a significant improvement, with an increase in A zone estimates and a decrease in...

New Paradigm

The immutable responsibility that patients have for the self-management of diabetes rests on three characteristics of the disease. First, the most important choices affecting the health and well-being of a person with diabetes are made by the person with the disease, not by diabetes educators or physicians. The choices that patients make about eating, physical activity, stress management, monitoring, etc. are the major determinants of their diabetes control. Each day, during the routine conduct of their lives, patients with diabetes make a series of choices that, cumulatively, have a far greater impact on their blood glucose levels, quality of life and overall health and well-being than the decisions made by the health professionals providing their care. It is not that the patient's life affects his diabetes care, it is that the patient's life is his diabetes care.

Coping

Coping dispositions show a better match with DM1 self-management demands than passive, avoidant coping. Active coping corresponds with better quality of life among adults with diabetes (12), and better metabolic control among adolescents with DM1 (13). Although much of the research investigating samples of patients with DM1 are adolescent samples, these data are relevant to our discussion, as most adults with DM1 have had the condition across their adolescent years, and may have developed coping dispositions that persist into adulthood. While some studies have shown that coping training interventions for adolescents produced reductions in diabetes-specific stress but not improvements in glycemic control (14), others have produced improvements in self-efficacy as well as metabolic control that maintained for 6 months following therapy (15). Simply put, it appears that individuals who manage stress by approaching the stressful condition, attempting to control the condition, and find the...

Stress

Stress can produce hormones that can shoot your blood glucose levels up and out of your desired range. Stress can also be a hidden contributor to unexpected swings in blood glucose levels. The effect of an angry driver who cuts you off on the interstate can't be as easily measured as grams of carbohydrate, units of insulin, or calories burned during exercise. When you can't figure out why your blood glucose level is so high despite doing everything right, think about the stresses in your life. Also, think about how you respond to stress. Do you eat when you are under stress This can bring up blood glucose levels. Do stressful situations make you more active than usual This response can decrease blood glucose levels.

Managing Anxiety

Everyone feels nervous or anxious from time to time, especially in a stressful situation. This is normal and, often, even helpful. Anxiety is a survival mechanism that can help you get through a difficult situation. If you are face-to-face with a man-eating bear or have to give a lecture before 1,000 people, for example, feeling a little anxious can help you get through the ordeal. But if you find that you feel nervous or anxious in situations that are not stressful to most people or if your anxiety is so intense and long-lasting that it interferes with day-to-day living, you may have a more serious problem called an anxiety disorder. The issue is not that your worries are unfounded, but that your worries are more intense, frequent, or last longer than others experience in a similar situation. Feelings of anxiety can coexist with feelings of depression.

Hyperglycemia

Small children can also develop swelling of the brain (cerebral edema). DKA can occur in people with type 1 diabetes who have not yet been diagnosed and can also develop during periods of stress or illness. When the body has to deal with a bacterial infection, a sickness such as the flu, or a stressful situation, hormones cause the liver to release stored glucose. These hormones also block the effects of insulin.

Coping strategies

In many ways, coping with a diagnosis of diabetes is like coping with any other severely stressful event. Research suggests that appraisal of a chronic disease as threatening or challenging leads to the initiation of coping efforts. Which strategies facilitate best psychological adjustment There is some evidence that, like coping with other stressful events, the use of avoidant coping is associated with increased psychological distress, and thereby may be a risk factor for adverse responses to illness. Similarly, poor adjustment has been associated with efforts to forget the disease, fatalism, passive acceptance, withdrawal from others, blaming of others and self-blame, and this form of coping has also been related to poor blood glucose control. In contrast to this, research has found lower psychological distress to be associated with positive, confrontative responses to stress and with beliefs that one can personally direct control over an illness.

Benefits Of Activity

The psychological benefits of exercise are equally important for the obese individual with Type 2 diabetes. Reductions in anxiety levels, improved body image and higher self-esteem promote greater self-efficacy and help the individual to cope with stressful situations which often result in overeating and relapses (71,72).

Treatment

Reduce their salt intake and consider other non-pharmacological measures such as stress reduction and relaxation. However, most patients will still need medication. Angiotensin converting enzyme (ACE) inhibitors are the first-line treatment, followed by beta blockers and thiazides, then calcium channel antagonists. Once-daily preparations are more likely to be remembered than multiple-dosage regimens. Obviously, all blood pressure lowering agents are capable of causing hypotension particularly postural hypotension which may be worse in patients with autonomic neuropathy. This should be sought by asking about postural dizziness or light-headedness, and by measuring lying and standing blood pressures. ACE inhibitors, beta blockers, and diuretics can all cause fluid or electrolyte imbalance. Many hypotensive agents interact with other drugs and this should be checked before prescribing. They can cause erectile dysfunction.

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