Category: Diet

Diabetic coma and emotional well-being

Diabetic coma and emotional well-being

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Diabetic coma and emotional well-being -

You can see how having a mental health problem could make it harder to stick to your diabetes care plan. Thoughts, feelings, beliefs, and attitudes can affect how healthy your body is.

Untreated mental health issues can make diabetes worse, and problems with diabetes can make mental health issues worse. But fortunately if one gets better, the other tends to get better, too. Depression is a medical illness that causes feelings of sadness and often a loss of interest in activities you used to enjoy.

It can get in the way of how well you function at work and home, including taking care of your diabetes. People with diabetes are 2 to 3 times more likely to have depression than people without diabetes. But treatment—therapy, medicine, or both—is usually very effective.

And without treatment, depression often gets worse, not better. If you think you might have depression, get in touch with your doctor right away for help getting treatment.

The earlier depression is treated, the better for you, your quality of life, and your diabetes. Stress is part of life, from traffic jams to family demands to everyday diabetes care. You can feel stress as an emotion, such as fear or anger, as a physical reaction like sweating or a racing heart, or both.

Your blood sugar levels can be affected too—stress hormones make blood sugar rise or fall unpredictably, and stress from being sick or injured can make your blood sugar go up. Being stressed for a long time can lead to other health problems or make them worse. Anxiety—feelings of worry, fear, or being on edge—is how your mind and body react to stress.

Managing a long-term condition like diabetes is a major source of anxiety for some. Studies show that therapy for anxiety usually works better than medicine, but sometimes both together works best. You can also help lower your stress and anxiety by:. Anxiety can feel like low blood sugar and vice versa.

It may be hard for you to recognize which it is and treat it effectively. There will always be some stress in life. But if you feel overwhelmed, talking to a mental health counselor can help. Ask your doctor for a referral. You may sometimes feel discouraged, worried, frustrated, or tired of dealing with daily diabetes care, like diabetes is controlling you instead of the other way around.

It happens to many—if not most—people with diabetes, often after years of good management. Fear of hypoglycemia FoH , for those with the potential for hypoglycemia, is a common occurrence and a major behavioural and emotional burden.

Hypoglycemic experiences, especially serious or nocturnal episodes, can be traumatic for both individuals and their family members. A common strategy to minimize FoH is compensatory hyperglycemia, where individuals either preventatively maintain a higher blood glucose level, or treat hypoglycemia in response to perceived somatic symptoms without objective confirmation by capillary blood glucose concentrations[ 34—37 ].

This process, if left unmanaged, can negatively impact glycemic target achievement, increase the risk of complications, and reduce quality of life. Figure 1 Determining perceived concerns and needs when considering medications.

Challenges accompanying the diagnosis of diabetes include adjustment to the illness, participation in the treatment regimen, and psychosocial difficulties at both a personal and an interpersonal level [ 38 , 39 ].

Stress, deficient social supports, and negative attitudes toward diabetes can impact on self-care and glycemic levels [ 40—44 ]. Diabetes management strategies ideally incorporate a means of addressing the psychosocial factors that impact individuals and their families. Both symptom measures e.

self-report measures of various symptoms and methods to arrive at psychiatric diagnoses e. structured interviews leading to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision [DSMTR] diagnoses [ 45 ] have been developed.

While DD, MDD, and the presence of depressive symptoms that do not meet the threshold for the diagnosis of MDD do share similar symptomatology, DD has been most shown to have the strongest effect in causing adverse diabetes outcomes [ 52—54 ]. Some of the distinguishing features between DD and MDD are summarized in Table 1.

Stigma—defined as the experience of perceived or direct social judgement social stigma —often results in discrimination or exclusion, including in health-care settings structural stigma.

Stigma has been also associated with both hyper- and hypoglycemia, as well as reports of a reduced sense of well-being and self-efficacy for managing diabetes [ 57 ]. Diabetes-related stigma is often associated with visible diabetes management activities e.

use of technology, blood glucose checks, verbalized rationale for food choices , leading to coping by avoidance with regard to diabetes care [ 57 ]. Approximately half of adults with T2D report experiencing both general diabetes-related stigma, as well as stigma based on weight status [ 58 ].

Endorsement of higher degrees of weight-based stigma i. Weight-based stigma may also occur in health-care settings and can negatively impact the quality of the patient-provider interactions [ 59 ], as well as health outcomes i. risk of elevated cortisol levels, higher blood pressure, decreased glycemic stability [ 60 ].

Health-care providers need to be aware of their own weight-stigma biases and language in their verbal and written communication [ 58 , 60 ]. Training in the use of motivational interviewing techniques to improve the quality of communication around weight-based discussions can be helpful [ 60 , 61 ].

Diabetes is a chronic condition associated with significant direct costs e. medications, diabetes supplies, travel to physician and allied health-care provider appointments, food plans recommended for diabetes, etc. decreased productivity, management of diabetes complications, hospitalizations related to diabetes, etc.

It has been found that treatment participation in diabetes care is affected by these direct and indirect costs [ 62 , 63 ]. People affected by diabetes tend to have lower incomes than the general population. When there are multiple members of a household living with diabetes, the impact will be even greater.

Similar to these Canadian statistics, data from other countries also illustrate how financial burden can affect the capacity of a person to manage their diabetes. For instance, people taking insulin a direct cost report cost-related underuse of this treatment, and are more likely to have higher glycemic levels as a result [ 64 ].

A recent study suggested that young adults with T1D who report increased financial burden of diabetes are far less likely to achieve glycemic targets compared to those that do not report financial burden of diabetes.

Cost concerns were described as all-consuming and a source of fear and feelings of isolation. Diabetes cost concerns intensified feelings of limitation and unfairness [ 65 ].

This is despite the fact that the direct drug costs were much higher in the adherent group [ 66 ]. Multiple studies have established that the increased costs of diabetes therapy are associated with inadequate adherence, which eventually affects outcomes.

Given the deleterious effects of cost-related underuse of therapy and the eventual complications of suboptimally controlled diabetes, it is imperative that health-care providers regularly ask about the affordability of therapy [ 67 ].

The National Health Interview Survey by the Centers for Disease Control and Prevention found that about The most common forms of insulin rationing included delaying purchase all insulin users , followed by taking less than required T1D more so than T2D [ 68 ].

Members of diabetes care teams should inquire about the financial burden the illness is causing and help with access to fiscal supports available through government and other community programs where applicable and available. Figure 2 Framework for understanding the intersection of mental health and diabetes.

Figure 3 Psychiatric conditions that increase the risk of developing diabetes. Figure 4 Diabetes increasing the risk of developing select psychiatric disorders. Individuals with serious mental illnesses—particularly those with depressive symptoms—and people with diabetes share reciprocal susceptibility and a high degree of comorbidity Figures 3 and 4.

The mechanisms behind these relationships are multifactorial, complex, and only partially understood. Second- and third-generation atypical antipsychotic agents are used to treat a wide variety of mental health conditions including as augmentation agents for major depression, OCD, as well as use as mood stabilizers for bipolar disorder in addition to their use in psychotic disorders , but can increase the risk of T2D [ 69 ].

Biochemical or physiological changes due to psychiatric disorders themselves also may play a role [ 70 ]. Symptoms of mental health disorders and their impact on lifestyle choices and practices are also likely to be contributing factors [ 71 ]. The interplay between psychiatric disorders and diabetes is illustrated in Figure 4.

The psychiatric disorders listed here principally but not exclusively contribute to the risk of developing T2D. People with intellectual disability or autism spectrum disorder were found to have a 1.

However, other studies have not established this risk, so these findings should be considered speculative [ 74 ]. The prevalence rate of T1D in people with Down's syndrome can be up to A population-based data study in Taiwan found children average age 8.

However, no significant association was observed between ADHD and T1D [ 76 ]. A robust finding across many studies is that the prevalence of T2D in people with schizophrenia and schizoaffective disorder is 2- to 3-fold higher than in the general population [ 77—81 ].

Schizophrenia and other psychotic disorders may contribute an independent risk factor for diabetes. The prevalence of metabolic syndrome was approximately twice that of the general population [ 85 ]. Diabetes and schizophrenia together lead to more cardiovascular complications and all-cause mortality compared to people with diabetes alone [ 86 ].

Whether the increased prevalence of diabetes is due to the effect of the illness such as advanced glycation end products , antipsychotic medications, or other factors, individuals with psychotic disorders represent a particularly vulnerable population [ 87 ].

Furthermore, repeated relapses in schizophrenia leads to a higher risk of developing diabetes than does the first episode of psychosis. Women also are at higher risk of developing diabetes.

Diabetes generally develops 1 to 2 decades after the onset of symptoms in serious mental illnesses, such as schizophrenia [ 88—92 ]. The dominant finding from studies suggests that the prevalence of T2D in people with bipolar disorder is 2 to 3 times higher than in the general population [81—84[, along with at least double the risk of metabolic syndrome [ 14 , 93 ].

One study demonstrated that over half of people with bipolar disorder were found to have impaired glucose metabolism, which was found to worsen key aspects of the course of the mood disorder[ 94 ]. In this same study, impaired glucose tolerance IGT was found to be an associative factor and possibly the precipitating step in the development of bipolar disorder [ 94 ].

While insulin resistance or IGT does not cause bipolar disorder, the associated inflammation may unmask bipolar disorder in people predisposed to developing it. Insulin resistance is associated with a less favourable course of bipolar illness, more cycling between mood states, and a poorer response to lithium [ 95 ].

Significant work has gone into unravelling the role of inflammation as an important etiologic factor in mood disorders more so for bipolar disorder than for MDD [ 96 ]. The risk of developing MDD increases the longer a person has diabetes [ ]. Clinically identified diabetes was associated with a doubling of the number of prescriptions for antidepressants.

People with undiagnosed diabetes were not given an increase in prescriptions for antidepressants. This strengthens the hypothesis that the relationship between diabetes and depression may be attributable to factors related to diabetes management [ ].

The prognosis for comorbid MDD and diabetes is worse than when each illness occurs separately [ ]. MDD in people with diabetes amplifies symptom burden by a factor of about 4 [ ]. Episodes of depression in individuals with diabetes are likely to last longer and have a higher chance of recurrence compared to those without diabetes [ ].

Episodes of severe hypoglycemia have been correlated with the severity of depressive symptoms [ , ]. MDD has been found to be underdiagnosed in people with diabetes [ ]. Studies examining differential rates for the prevalence of depression in T1D vs T2D have yielded inconsistent results [ 97 , ].

One study found that the requirement for insulin was the factor associated with the highest rate of MDD, regardless of the type of diabetes involved [ ].

Treatment with metformin may enhance recovery from MDD in T2D [ ]. Risk factors for developing MDD in individuals with diabetes are as follows [ — ]:. Risk factors with possible mechanisms for developing diabetes in people with depression are as follows:.

Some of the mechanisms underlying this association are thought to be autonomic and neurohormonal dysregulation, hippocampal structural changes, inflammatory processes, and oxidative stress [ ]. Comorbid MDD worsens clinical outcomes in diabetes, possibly because the accompanying lethargy lowers the energy available for self-care, resulting in lowered physical and psychological fitness, higher use of health-care services, and reduced participation in medication regimens [ , ].

MDD is also associated with increased cardiovascular mortality [ — ]. Treating depressive symptoms more reliably improves mood than it does glycemic stability [ — ].

MDD increases the risk of all-cause hospitalizations for persons treated for diabetes. This increased risk is independent of medication self-management difficulties, or other potential factors [ ].

Inadequate social support increases the risk of MDD in people with T2D [ ]. There does not appear to be a significant association between the severity of depressive symptomatology and higher A1C levels. However, increased depressive symptomatology was associated with higher A1C values among participants with fewer social supports [ ].

Anxiety is commonly comorbid with depressive symptoms [ ]. Anxiety disorders were present as comorbid conditions in one-third of people with serious mental illnesses and T2D, and were associated with increased depressive symptoms and decreased level of function [ ].

A year follow-up study in Australian women suggests that long-term anxiety has been associated with an increased risk of developing T2D across the reproductive span [ ].

Alternately, in an epidemiological study with year follow-up, no significant relationship was found between anxiety and development of diabetes-related complications among those with prevalent T2D.

This large study showed that anxiety disorders were not associated with a greater risk of developing T2D or the risk of diabetes complications in people already diagnosed with diabetes [ ]. A multicentre international study spanning 15 countries looked at people aged 18 to 65 years with T2D treated in outpatient settings who were administered the Mini-International Neuropsychiatric Interview.

The study found that female gender, the presence of diabetes complications, longer duration of diabetes, and more glycemic instability were significantly associated with comorbid anxiety disorders [ ]. Compared to people with OCD who do not take serotonin reuptake inhibitors, those taking higher doses of these medications and who had a longer duration of treatment demonstrated significantly diminished risks of metabolic and cardiovascular complications, irrespective of whether they were also taking antipsychotic medications [ ].

A history of significant psychological adversity or trauma—particularly early in life—increases the risk for developing obesity, diabetes, and cardiovascular disease [ ]. Higher BMI, leptin, blood pressure, fibrinogen, and decreased insulin sensitivity have been found in people with significant trauma histories [ ].

Traumatic symptoms may increase the risk for developing diabetes and other cardiovascular illness through reduced physical activity, poorer diet, greater likelihood of tobacco consumption, escalating BMI, and MDD [ ].

There is a significant association between psychological trauma and higher A1C values. Adequate social support can attenuate the association between psychological trauma and A1C values [ ].

No conclusive evidence could be found at the time of writing regarding an association between dissociative identity disorder and diabetes, apart from a case report about hyperglycemia-associated dissociative fugue organic dissociative disorder in an older male [ ].

Non-specific premonitory symptoms can be prodromal signs of illnesses well before actual onset, and this includes T2D [ ]. Somatic symptoms prior to the onset of T2D are chiefly related to hyperglycemic states and acute metabolic disturbances, with key symptoms being polyuria, polydipsia, weight loss sometimes along with polyphagia , and blurred vision.

People reporting these symptoms are at increased risk of developing T2D [ ]. Anorexia nervosa, bulimia nervosa, and binge eating disorder BED have been found to be more common in individuals with diabetes both T1D and T2D than in the general population [ ].

Eating disorders are common and persistent, particularly in females with T1D [ , ]. Elevated BMI is a risk factor for developing both T2D and MDD [ ]. NES has been noted to occur in individuals with T2D and depressive symptoms. NES can result in weight changes, poor glycemic management, and an increased number of diabetes complications [ ].

T1D with disordered eating T1DE —often called diabulimia—is an eating disorder that only is seen in people with T1D when they decrease or stop taking their insulin in an attempt to lose weight.

Although diabulimia is not a formal diagnosis, it has garnered significant exposure in the media that medical and psychiatric communities acknowledge the term. Offering psychological support is the mainstay of treatment for people with diabulimia.

People with diabetes commonly experience problems with bladder and bowel control. However, no conclusive evidence is presently available to support a more formal association between elimination disorders and diabetes. The elevated risk is comparable to traditional risk factors for T2D, such as having excess weight, having a positive family history, and physical inactivity.

Pooled relative risks RRs of total sleep time are:. Poor sleep quality, OSA, and shift work were associated with greater risk of developing T2D, with a pooled RR of 1.

In comparison, the pooled RRs of living with overweight, having a family history of diabetes, and being physically inactive were 2. Both T1D and T2D are established risk factors for sexual dysfunction in men [ ].

There is a 3-fold greater risk of erectile dysfunction ED in men with diabetes compared to those who do not have it, likely due to vascular causes [ , ]. Women with either T1D or T2D have been found in some studies to have an increased prevalence of sexual dysfunction compared to women without diabetes [ , , ].

Female sexual dysfunction appears to be more likely due to secondary social and psychological impacts of diabetes rather than the direct physiological consequences [ , , ].

There is no robust evidence available at this time showing that other sexual or paraphilic disorders have an association with diabetes [ ]. An increased prevalence of T1D in transgender children and adults has been described up to 9. However, the correlation of T1D with gender dysphoria appears to exist equally for all transgender populations [ , ].

Various factors may explain the increasing prevalence of T1D in transgender populations, including psychological stress. Clinicians should attempt to look for environmental triggers, such as psychological minority stress defined as the relationship between minority and dominant values and resultant conflict with the social environment experienced by minority group members experienced by young people with gender dysphoria.

Such sources of stress may affect the pathogenesis and management of T1D. Better clinical outcomes may result with early detection and adequate support. A Dutch case-control study found an increased prevalence of T2D among transgender populations when compared to both age-matched, non-transgender males and females, though this study did not adjust for other risk factors [ , ].

In a study of the effects of administering gender-affirming hormones on insulin sensitivity in transgender populations, transgender women those receiving estrogens or anti-androgens evidenced a reduction in markers of insulin sensitivity; there was no change in transgender men those receiving androgenic medications [ ].

People with established diabetes undergoing gender-affirming surgeries constitute a special group for whom efforts to effectively manage glucose levels is desirable.

Although the diagnosis of diabetes in itself may not be a contraindication for any of these procedures, interprofessional coordination between the surgical team and the clinicians managing the diabetes is advisable [ ]. At present, there appears to be no significant relationship between receiving gender-affirming hormone therapy and diabetes risk, or impact on established diabetes.

Accordingly, no specific recommendations can be put forth at this time for diabetes screening in transgender populations, regardless of hormone administration status.

In a study of 50, people using data from 19 countries, the authors identified 2, cases of adult-onset diabetes diagnosed in individuals aged 21 years and older. After factoring for the presence of comorbid MDD, this study found that, among impulse-control disorders, only intermittent explosive disorder appeared to be an independent risk for diabetes OR 1.

People whose weight is in the obese range but who do not have T2D have been found to have somewhat more rigid behaviours along with more compulsive personality traits compared to people with both obesity and T2D, who may demonstrate more impulsivity with their decisions, which may negatively influence diabetes self-management [ ].

The exact prevalence of substance use disorders among individuals with diabetes is difficult to establish, and the presence of substance use disorders may contribute to unique challenges in this population. Recreational substance abuse is associated with increased rates of hospitalization and readmissions for diabetic ketoacidosis DKA [ ].

Furthermore, substance abuse and psychosis among individuals with T1D and T2D increases the risk of all-cause mortality [ — ].

T2D is a recognized risk factor for the development of various subtypes of dementia and mild cognitive impairment [ ]. MDD is an important risk factor in the development of cognitive impairment in people with T2D, the risk being 2. Although certain inflammatory markers, such as C-reactive protein and interleukin 6 IL-6 , are associated with MDD, there is presently no clear link supporting the hypothesis that systemic inflammation mediates the relationship between MDD and dementia [ ].

Personality traits or disorders that put people in constant conflict with others or engender hostility have been found to increase the risk of developing T2D [ ]. People with chronic, significantly negative mood states and social inhibition were less likely to follow a healthy diet or to consult health-care professionals when problems developed with their diabetes management.

They report more barriers surrounding medication use, diabetes-specific social anxiety, loneliness, and symptoms of depression and anxiety [ ]. A population-based, matched cohort study in Denmark found an increased risk of personality disorders unspecified in only girls with a diagnosis of T1D.

An Australian study confirmed an overall increase in the risk of personality disorders of more than 2-fold following T1D onset, but did not differentiate between sexes [ ].

In T2D, impaired personality functioning, as manifested by greater difficulties in personal relationships, mood dysregulation, impulse-control problems, and problems with interpersonal communication were correlated with deterioration in plasma glucose levels during the first 6 months of a standardized disease management program.

However, the degree of depressive symptoms did not show this correlation [ ]. Neuroticism—the disposition to experience negative emotions—including anger, anxiety, self-consciousness, irritability, emotional instability, and depression is associated with decreased T2D risk, even after controlling for ethnicity, age, depressive symptoms, and BMI.

Type A behaviour is characterized by a constant sense of time pressure, a strong appetite for competition, and the achievement of goals.

Extraversion and Type A behaviours do not appear to be significant risk factors for T2D [ — ]. A descriptive cross-sectional study examined participants with T1D and controls. People with high levels of resiliency estimated their degree of diabetes management inaccurately by reporting a high degree of perceived adherence, which was not in keeping with their more objective A1C levels suggesting overconfidence.

With respect to psychological health factors, people who demonstrate more resilience appear to have better overall adjustment, demonstrating fewer emotional problems in managing T1D.

Two independent systematic reviews with meta-analyses showed that MDD significantly increases the risk of all-cause mortality among individuals with diabetes compared to those with diabetes without MDD [ , ].

Older adults with diabetes and MDD may be at particular risk [ ]. Individuals with bipolar disorder, schizophrenia, or other psychotic disorders, and who have comorbid diabetes, are at increased risk of rehospitalization following medical-surgical admissions [ ].

A large prospective cohort study determined that the presence of MDD in people with both T1D and T2D is associated with greater risk of developing chronic kidney disease compared to people without MDD [ ].

Comorbid MDD or anxiety are associated with significantly longer hospital length of stay, as well as for adolescents with T1D hospitalized for DKA [ ]. A meta-analysis of 11 cross-sectional and prospective cohort studies showed that MDD is significantly associated with higher incidence of diabetic retinopathy in individuals with T2D.

However, it is unclear if this is a causal association [ ]. Two studies reported an increase in length of stay of close to 4 days in individuals with diabetes and a comorbid mental illness [ , ].

Individuals with T2D are more likely to have a longer length of stay in inpatient mental health settings compared to people with T1D. Those with T2D are likely to have more comorbid conditions, increasing illness severity and necessitating longer hospital stays.

More resources are likely to be needed to ensure a safe and seamless hospital discharge. The needs of people with T2D may be different than those with T1D, but it is unclear if the difference in pathophysiology alone accounts for differences in length of stay [ ].

A recent systematic review of the associations between gestational diabetes mellitus GDM , anxiety, and depression in pregnant individuals found a bidirectional relationship in that anxiety and depression as well as other stressors, such as a history of childhood sexual abuse and experiencing intimate partner violence during pregnancy resulted in a higher incidence of GDM [ ].

Additionally, a diagnosis of GDM increased the subsequent incidence of anxiety and depressive disorders [ ]. Another meta-analysis indicated that the highest levels of depressive symptoms for individuals with GDM occur right around the time the condition is diagnosed [ ].

This may be due to the increased psychological strain of having a new diagnosis that could negatively impact pregnancy outcomes and the increased demands in diabetes self-management tasks [ ].

However, a population-based study in Canada explored mental illness rates including anxiety and MDD in individuals prior to pregnancy, during pregnancy, and postpartum. It was found that, although the prevalence of mental health issues was higher in those with GDM versus those without GDM, there appeared not to be a temporal relationship between GDM and subsequent incidence of psychiatric diagnoses [ ].

Differences were hypothesized to be more likely related to gestational increases in weight [ ]. Additionally, there did not appear to be significant mental health differences in those diagnosed with GDM early in pregnancy versus during the typical screening period for GDM in pregnancy [ ].

Despite these disparate findings, the consensus is that there is a higher prevalence of psychiatric symptomatology in individuals with GDM and that the symptoms are often underdiagnosed [ ]. Screening instruments and rating scales, such as the single-item Self-Rated Mental Health Question SRMHQ , can be helpful in individuals with GDM [ ].

A study using mindfulness-based counselling interventions has demonstrated some initial effectiveness in decreasing anxiety in individuals with GDM, but more research is needed to compare this treatment with other evidence-based approaches [ ], as well as examine whether lifestyle-based interventions that address weight fluctuations during pregnancy are effective at reducing depression symptoms [ ].

Another study examined the trajectory of depressive and anxious symptoms in a group of individuals with PGM only, and the results indicated that these symptoms remained unchanged from early to late pregnancy [ ].

Optimal support for this population would involve:. GDM, PGM, and postpartum depression: A population-based study examining postpartum depression PPD rates in individuals with diabetes in pregnancy DIP , which includes individuals with either GDM or PGM, found a 1.

Another recent meta-analysis replicated the association between those with DIP and PPD but cautioned that when those with GDM versus PGM were compared, the individuals with GDM were the ones more at risk for developing PPD [ ]. Another study found that although individuals with DIP all had significant levels of distress, the highest level of negative pregnancy outcomes was found in those with PGM and negative psychological outcomes were found in individuals with GDM [ ].

The SARS-CoV-2 COVID pandemic can also worsen symptoms. In addition, 2 factors unintended pregnancies and lower social support were associated with higher levels of anxious and depressive symptoms for individuals with DIP.

This may also be related to the effects of social isolation during the pandemic based on fears of a more severe COVID infection for those with diabetes [ ], which may improve with diabetes education and medical support that focuses on the emotional burden of DIP and diabetes regimen-related concerns [ ].

Individuals with pregnancy in diabetes have a higher prevalence of various psychiatric conditions particularly mood and anxiety disorders , which are often underdiagnosed [ ]. One study found that higher levels of medical support experienced by individuals with DIP significantly reduced levels of anxious and depressive symptoms and may buffer the negative outcomes [ ].

For children and adolescents, there is a need to identify mental health disorders and psychosocial issues associated with T1D in order to be able to institute early interventions. Children and adolescents with T1D have significant risks for mental health issues, including depressive symptoms, anxious symptoms, altered feeding and eating, and disruptive behaviours [ — ].

These risks increase significantly during adolescence [ , ] and into young adulthood. Studies have shown that mental health disorders predict difficulties with diabetes management and glycemic variability [ — ] and worsen medical outcomes [ 47 , — ].

The more glycemic levels are not within target range, the probability of mental health issues also increases [ ]. Adolescents with T1D have been shown to have rates of DD that are comparable to adults with T1D [ 16 ]. An initial study of parental self-report suggests that the use of hybrid closed-loop systems for insulin delivery in children may help ameliorate some parental FoH and poor sleep quality symptoms that may lead to improved glycemic stability for the child [ ].

Maternal anxiety and depressive symptoms are often associated with higher glucose instability and school absenteeism in younger adolescents with T1D, and a reduction in positive mood and motivation for their own diabetes care in older teens [ , ].

Eating disorders are also associated with less metabolic stability, in addition to an earlier onset and faster progression of microvascular complications [ ]. Adolescent and young adult females with T1D who have difficulty achieving and maintaining glycemic targets—particularly if insulin omission is suspected—may also have problematic eating behaviours including subclinical disordered eating behaviours and eating disorders.

Individuals with disordered eating behaviours may require different management strategies to optimize glycemic stability and prevent microvascular complications [ ]. The prevalence of anxiety disorders in children and adolescents with T1D in one study was found to be The presence of psychiatric disorders was related to elevated glycemic levels and a lowered health-related quality of life score in a general pediatric quality of life inventory study [ ].

In the diabetes mellitus—specific pediatric quality of life inventory, children with mental health disorders revealed more symptoms of diabetes, higher treatment barriers, and lower self-management behaviours than children without mental health disorders [ ]. Adolescents with T1D ranked school as their number 1 stressor, their social lives as number 2, and having diabetes as number 3 [ ].

Children and adolescents with T1D, as well as their families, benefit from screening for mental health disorders and psychosocial issues also referred to as person-reported outcome measures [PROMs] at the time of diagnosis, as well as at regular intervals [ ].

Given the prevalence and impact of mental health issues, psychosocial screening of children and adolescents with T1D is just as important as screening for microvascular complications [ , ]. A promising addition to traditional in-person clinic visits is the use of telehealth services, which increased out of necessity during the COVID pandemic but may be a lasting option.

Online meeting rooms, such as virtual group appointments or digital health interventions e. mHealth apps demonstrate improvements in diabetes-related distress [ ] and self-efficacy [ ], as well as parental ratings of quality of life [ ].

In order to prepare for the transition from pediatric to adult diabetes care, a transition plan should be initiated at around 12 years of age so that services including diabetes education, transition readiness assessments, setting transition goals, etc.

can occur early enough to prepare adolescents and their families [ , ]. Psychological interventions, which include cognitive-behavioural as well as other complementary psychotherapy approaches e.

art therapy , have a positive impact on mental health of children and adolescents with T1D and their families [ , ], including overall well-being [ ], perceived quality of life [ , ], and reduction in depressive symptoms [ , ]. Psychosocial interventions can positively affect glycemic stability[ , ].

Other studies have demonstrated that psychological interventions can increase both diabetes self-management behaviours and frequency of in-target glycemic levels, as well as overall psychosocial functioning [ , ].

Mental health concerns play a significant role in children and adolescents with T2D across all ethnic groups, particularly depression [ ] and binge eating behaviours [ ]. These psychosocial issues, along with disruptive sleep habits [ ], are associated with lower diabetes self-management success and quality of life [ , ].

Moderate-to-severe depression rates in young adults who were diagnosed with T2D in childhood have also been associated with high levels of DD [ ]. Presently, there is a lack of high-quality research data on the impact of MDD and depressive symptoms in youth with T2D.

The majority of the studies in this population do not assess for a formal diagnosis of MDD, although depressive symptoms are common in youth and more likely to be associated with adverse diabetes outcomes [ ].

T2D does not appear to be more common in geriatric-aged people with psychiatric conditions than similarly aged controls. The risk of developing a dementing illness in people is increased in those who have MDD hazard ratio [HR] 1. The presence of depressive symptoms in older adults with T2D is associated with increased mortality risk [ ].

Totalling the PHQ-9 scores for the symptoms of diminished interest, sleep changes increase or decrease , psychomotor changes retardation or agitation , and diminished concentration symptoms to 4 or above has an enhanced specificity for detecting MDD in older people [ ].

Overweight status, limited physical capabilities, and reduced activity level, along with the presence of more than 2 comorbid illnesses, were risk factors for MDD in older people with diabetes mellitus. In a case—control study done in China, metformin was found to reduce the risk of developing MDD in older people with diabetes [ ].

Access to ongoing psychosocial interventions through technological platforms may potentially minimize diabetes complications and improve health-related outcomes [ , ].

Telehealth-related technologies can be effective in improving the clinical, behavioural, and psychosocial outcomes in people with diabetes above 50 years of age. Prescription choices for older people with diabetes mellitus and MDD should factor in antidepressants with a higher likelihood of safety and tolerability [ ].

Recreational substance use is common in Canada. Among the general population, the prevalence of consumption is: [ , ]. Most studies find that prevalence of substance use among people with diabetes mirror the prevalence rates found in people without diabetes.

Excess substance use leads to physical health complications in major organ systems leading to increased morbidity and premature mortality. This makes substance use among people with diabetes of particular concern because of the additive health risks.

Evidence suggests that substance use has a complex effect on diabetes. In people without diabetes, consumption of tobacco or alcohol increases the risk of developing diabetes [ , ]. In persons living with diabetes, substance use is linked with adverse health outcomes, particularly complications of diabetes [ , ].

These observations can be partly explained by the deleterious effects of the substance directly on glucose homeostasis. A large body of literature suggests that substance use is associated with greater risk for the development of T2D [ , ].

A meta-analysis of 25 cohort studies found an increase in the relative risk for new-onset diabetes among people who smoke cigarettes RR 1. The heightened risk for heavier smokers has a number of hypotheses, including the stimulant effects of nicotine leading to insulin resistance, the potentially toxic effects of substances e.

heavy metals found in tobacco on the pancreas, and the positive correlation between the number of daily cigarettes smoked and abdominal obesity [ ]. Quitting smoking, while having a myriad of health benefits, paradoxically appears to be associated with a transient increase in the risk of new-onset diabetes.

In the first years after quitting, the hazard ratio for new-onset diabetes in successful quitters is higher than with active smokers HR 1. This risk peaks years after quitting and declines over time [ ].

The modest elevation in risk for new onset of diabetes after quitting does not negate the benefits of quitting smoking on cardiovascular health, as evidenced by a decrease in the incidence of acute coronary events and death [ ]. On a cross-sectional level, the lowest risk for new-onset diabetes appears to be among those with moderate alcohol consumption.

The relationship was curvilinear, with highest risks observed in those with alcohol consumption over 4. Events such as acute pancreatitis that follow heavier episodes of alcohol consumption are an established risk factor for new-onset diabetes [ ].

Some studies suggest that the type of alcohol consumed may also influence the health benefits, with wine conferring greater risk reduction benefits than beer or spirits [ ]. Compared with tobacco and alcohol, there is less evidence regarding the association of cannabis use and new-onset T2D.

Two cross-sectional studies actually detected a modest reduction in the prevalence of obesity and diabetes among people who use cannabis [ , ], while 2 cohort studies reported conflicting results; one showing an increase in risk for pre-diabetes among those who consume cannabis that was not observed in the other [ , ].

Limited evidence exists regarding the risk of T2D in people who use opioids for non-medical purposes. Prescription opioids do not appear to be associated with an increase in the risk of new-onset diabetes [ ]. Nevertheless, people with opioid use disorders who receive opioid agonist therapy OAT with methadone appear to be at a higher risk for developing diabetes compared with those receiving naloxone-buprenorphine [ ].

It is well-established that regular, sustained substance use is associated with unfavourable health outcomes. Among persons with diabetes, those with heavy substance consumption patterns exhibit higher rates of diabetes-related morbidity and earlier mortality [ ]. The deleterious effects of substance use vary with age and type of diabetes.

The propensity of substances to worsen glycemic stability has been attributed to a direct effect on glucose homeostasis and an indirect effect mediated through diminished levels of diabetes self-management [ ].

Cigarette smoking can interfere with glucose homeostasis among persons with T1D. Smoking is linked with greater odds of hypoglycemic events OR 2. Compared with non-smokers, smokers spent greater time in either hypoglycemic or hyperglycemic states and less in normoglycemia [ ].

Hypoglycemia could be partly explained by a co-consumption of cigarettes and alcohol [ ] and by inadequate diabetes self-management found among smokers [ ].

In persons with T1D, alcohol reduces plasma glucose levels and interferes with hypoglycemic counter-regulatory mechanisms. The onset of hypoglycemia usually appears hours following alcohol consumption.

The sedating effect of alcohol may also reduce the awareness of hypoglycemia. Together, these effects of alcohol can increase the risk of severe hypoglycemic events [ ].

Alcohol use among people with T1D can interfere with disease self-management and lead to missed doses of insulin [ ], which may explain the greater risk of DKA among young people with T1D who misuse alcohol [ , ].

Managing alcohol consumption can be a challenge for young people in an environment that promotes alcohol use, such as post-secondary institutions [ ]. Stimulants e. cocaine, methamphetamine are linked with hyperglycemic events though their stimulation of sympathetic transmission.

Elevated catecholamine levels counter the effects of insulin, and, in combination with missed doses of insulin, can lead to DKA [ ]. There is limited evidence available currently in the way of studies regarding the effect of cannabis use on people with T1D.

Cannabis can interfere with glucose homeostasis indirectly via its appetite-promoting tendencies, and directly by an effect on gastrointestinal motility that can lead to vomiting.

Cannabis may also interfere with self-management routines [ ]. A recent study using the T1D Exchange Clinic Registry found that adults with T1D who reported moderate cannabis consumption had 2.

This group was associated with a 4-fold earlier mortality rate compared to the general population [ ], with substance use being identified as a significant contributor [ , ]. A recent meta-analysis of longitudinal observational studies confirmed the deleterious effects of smoking on the health of people with diabetes.

Compared with people who have never smoked tobacco, smoking had greater relative risks for early mortality RR 1. People who had quit smoking showed lower levels of risk for cardiovascular events and death compared with active smokers, but still had higher rates compared with lifetime non-smokers [ ].

Data analysis by gender suggests that women who smoke have a greater risk for cardiovascular events and death compared with men. However, men and women appear to benefit equally from quitting [ ]. The elevated risk for cardiovascular events and death associated with smoking can be attributed to its direct effect on insulin resistance, leading to worsening of glycemic levels as well as the propensity for atherosclerosis [ ].

It is also suggested that smoking is associated with more difficulties in diabetes self-management practices [ ]. The health effects associated with alcohol drinking among people with diabetes may follow a curvilinear relationship [ ]. People who drink 1 standard drink per day appear to have the lowest risk for cardiovascular events, even lower than people who abstain.

People consuming over 2 drinks per day have an associated greater risk than abstainers. The associated cardiovascular risk increases linearly with every drink beyond 2 drinks per day [ ]. Alcohol is thought to be particularly detrimental to health when consumed in higher quantities.

People diagnosed with alcohol use disorder experience worse outcomes compared to those without this condition. This includes higher odds ratio for myocardial infarction OR 1.

Heavy drinking is also linked with negative diabetes outcomes, such as increased odds for diabetic neuropathy OR 1. Similar to smoking, the effects of alcohol consumption in higher quantities appear greater among women relative to men with diabetes in terms of mortality [ , ].

Engaging in heavier alcohol consumption appears to be particularly detrimental to the health of individuals treated with insulin, who are associated with a 6- to fold greater risk for alcohol-related mortality compared with groups without diabetes matched for alcohol consumption [ ].

Beyond the direct effect on glucose homeostasis, alcohol use was also found to predict lower adherence with diabetes self-management behaviours [ ]. There is limited evidence that alcohol use disorder may interfere with participation in structured self-management diabetes education programs [ ].

Information regarding the effect of other substances such as opioids, cannabis, and stimulants on diabetes-related complications is limited at this time. However, one study found a greater odds ratio for early mortality in people with diabetes who use cocaine OR 1.

Dealing with comorbid chronic pain may distract both providers and people with diabetes from focusing on the management of diabetes [ ]. This may partially explain why the use of prescribed opioids has been linked with poorer quality of diabetes care, including reduced lipid and glucose monitoring [ ].

There is limited evidence of the effect of long-term OAT on persons with diabetes. Nevertheless, the use of methadone as OAT has been linked with an enhanced preference for sugary or low nutritional quality foods that may promote weight gain and worsen diabetes management Table 2.

Systemic screening for and documentation of smoking status is widely endorsed in most health-care settings, and smoking cessation is promoted as a key activity for people with diabetes i.

Individuals who smoke tobacco should be offered support for quitting. Brief interventions for smoking even lasting just minutes include psychoeducation on the benefits of quitting, assessing the level of interest in making a quit attempt, and responding appropriately with treatment or referral for treatment 5As: A sk, A dvise, A ssess, A ssist, A rrange.

For those not ready to quit, a brief intervention can help individuals identify the relevance of quitting to support favourable diabetes and health outcomes.

Elucidation of the existing barriers and identification of opportunities for change can be achieved by discussing the 5Rs of smoking: R elevance, R isk, R eward, R oadblocks, R epetition.

Brief interventions, such as the 5As and 5Rs, increase the odds of quitting successfully [ ]. People with T1D and T2D have similar success rates to populations without diabetes when using approved treatment for smoking cessation.

Quitting success is enhanced when individuals attempt to quit with approved pharmacotherapy e. nicotine replacement therapy, varenicline, bupropion, etc. combined with behavioural counselling [ , ]. Systematic screening for alcohol use in health-care settings can increase identification and timely treatment of alcohol misuse.

The most common screening tool for alcohol is the Alcohol Use Disorders Identification Test AUDIT-C. AUDIT-C screens for the frequency and intensity of alcohol consumption [ ]. Scores range from and a positive screen is 3 or 4 and above for women and men, respectively.

These brief interventions are called SBIRT s creening, b rief i ntervention, and r eferral for t reatment , and have been shown to be effective for both the general population and people with T1D and T2D [ , ].

Recently, SBIRT has been delivered through the internet and found to be effective in reducing alcohol consumption among college students with T1D [ ]. Persons who are unable to make changes to their alcohol use on their own should be offered a referral to specialized addiction treatment.

Treatment consisting of addiction counselling and anti-craving pharmacotherapy is the mainstay of care for people with an alcohol use disorder. Approved anti-craving pharmacotherapy e. naltrexone, acamprosate, or disulfiram increase the success of addiction psychosocial counselling and are safe for use in people with diabetes.

The lowest risk for health-related harm was seen in people who consume 2 or less standard drinks per week [ ]. Alcohol consumption at a level of standard drinks per week is associated with increased risk for cancer, and 7 drinks per week or more increases cardiovascular risk [ , ].

Legalization of cannabis in Canada in led to an increase in use amongst all age groups, but young people in particular. Legalization was followed by a position paper in from Diabetes Canada [ ].

These recommendations include avoiding cannabis use during adolescence, avoiding high-potency THC products i. concentrates and synthetic cannabis e. Following these recommendations may also reduce diabetes-related adverse effects that have been associated with cannabis, such as poor diabetes self-management, glycemic instability, and DKA [ ].

Individuals who are unable to decrease their cannabis use on their own should be offered a referral to specialized addictions treatment. To date, there are no approved medications for the treatment of cannabis use disorder, and addiction counselling is considered the mainstay of care [ ].

Most recently, there is some evidence to suggest that glucagon-like peptide-1 GLP-1 receptor agonists may play a beneficial role in the treatment of a number of substance use disorders, including tobacco and alcohol.

Since this class of medications is currently approved for use in people with T2D, it may be helpful in the treatment of persons with co-existing T2D and substance use disorders [ ], however, conclusive evidence is lacking at this point in time.

A review article found that people with both T1D and T2D had increased rates of suicidal thoughts, suicide attempts, and completed suicide compared to the general population [ ]. A systematic review and meta-analysis of more than 50 studies reported that individuals with T1D have a risk of completed suicide 2.

A study of Canadian adolescents and adults reported that individuals with T1D had a higher lifetime prevalence of suicidal ideation A thorough literature review with practical recommendations for providers e.

This will help stop stress building Creatine safety precautions and affecting Ad emotional well-bwing. Find out what Diabetic coma and emotional well-being is, how it affects diabetes and what emotkonal can do to change things. Stress is how your body and mind reacts to new or difficult situations. It can also be something physical like an accident or illness. Or you may have less immediate but more constant worries about things like money, a relationship or coping with the loss of someone close.

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Diabetic Coma - What Is IT and how it HAPPENS

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