Our body responds to stress by releasing hormones that increase glucose levels to provide muscles with the fuel they need to engage in battle. This system works well if you don’t have diabetes. However, for people living with insulin deficiency and /or resistance, chronic stress can make glycemic control even more challenging. In addition, stress can cause a detour in the best laid plans to eat healthier and exercise more. Hence, the “Double Whammy” of diabetes and stress.

We asked our special guest contributor to share her expertise on stress and provide us with some coping strategies we can pass along to our patients. Thanks Cathy!

How does daily stress impact people?
Most adults experience some level of stress on a daily basis.  Everything from the minor annoyance of a traffic jam to the life-altering commitment of caring for a chronically ill family member can lead to the familiar feelings of uneasiness, muscle tension, difficulty concentrating, changes in sleep and appetite, irritability, headaches, gastrointestinal problems, increased heart rate, trembling, and even feeling faint.  Stress affects the physical functioning of the body as well as common behaviors, making it particularly challenging for people with diabetes.

How does stress increase blood glucose levels?

When faced with a stress or danger, the body initiates an immediate and well-coordinated fight or flight response that allows 
a person to fight the danger or flee it.  Stress hormones, like adrenaline and cortisol, are released causing an elevation in glucose levels. In people without diabetes, this glucose surge is beneficial; it provides energy for muscles to fight off the danger or to outrun it. The system is based on the assumption that the extra glucose will be spent while conquering the dangerous situation, allowing the body to return to a normal (baseline) state. For centuries this system has allowed humans to always be ready to handle threats to their survival.

How have the effects on stress impacted human’s overtime?

It’s rare for modern stressors to require physical fighting or fleeing.  Stressors are more often encountered while sitting still — paying bills, sitting in traffic, working at a desk, or having a difficult conversation. Unfortunately the fight or flight response is so ingrained and automatic that it does not allow for differentiation between stress that requires action and stress that requires other types of responses. If the stressor does not necessitate the use of muscles, glucose levels can climb in the bloodstream stimulating the pancreas to increase insulin release.

What is the impact of stress on people with diabetes?

Stress has a dual effect on diabetes. Life stressors can affect behavior by influencing decision-making abilities (such as snacking on unintended foods or skipping exercise). Plus, stress activates the body’s fight or flight response increasing glucose levels circulating in the blood. Recognition of the double impact of stress on individuals with diabetes highlights the need for effective stress management as an integral part of diabetes management programs. 

What are some tools that Diabetes Educators can share?

Several techniques can be employed to help alleviate stress. Perhaps the most important skill is to learn to identify stressors. Often individuals report feeling weighed down and stressed out.  It can be surprisingly difficult to pinpoint the causes of those feelings.  However, taking some time to discuss them with another person can be helpful in naming the stress-causing demands on their lives.  Once identified, one can work to lessen or eliminate the stress or to increase their ability to manage the stress.

There are numerous effective ways to reduce feelings of stress, making it possible to find a technique that fits into the lifestyle and values of the individual who will be using it. An active, energetic person might find that exercise is a great stress-reducer. Alternatively, a person who values calm and quiet may prefer taking several slow, deep breaths to encourage relaxation.

Several relaxation techniques, such as progressive muscle relaxation (PMR), meditation, journaling and guided imagery, have actually been shown to reduce glucose levels in people with diabetes in addition to reducing feelings of stress.  There are many books and internet resources available that can provide more detail or instruction on these techniques.  In some cases, individuals find it helpful to enlist the help of a therapist who is trained in ways to help reduce stress and change thought patterns.

While no one likes the feeling of stress, it’s clear that it is especially detrimental to those with diabetes.  Featuring stress management in diabetes management programs can bring about positive changes psychologically as well as physically.

Special thanks to our guest contributor, Cathy A. Bykowski, from Tampa, Florida. Her research and clinical interests revolve around the relationship between mental and physical health, and in particular, how psychological factors affect diabetes outcomes. She is actively recruiting participants for her FREE Stress and Mood Management Program to complete her PhD. Please share this valuable resource with your patients.

Here is a fact: oral health and blood sugars are inter-related and regular dental care for people living with diabetes is critical.

A close look at the 2015 ADA Standards of Care, reveal that referral to a “Dentist for comprehensive periodontal examination” is situated right under referral to a “RD for MNT,” and referral for “DSME/DSMS” within the “Components of the comprehensive diabetes evaluation,” on page s18.

As diabetes educators, we have an opportunity to learn more about the dynamic relationship between these two conditions and encourage patients to be active participants in their oral health.

Here are the questions we posed to our expert contributor, Jerry Brown, DMD, CDCES.  His responses appear below.

1)  What is the relationship between hyperglycemia and oral health?

Wow! That is normally a 60 – 90 minute presentation! Diabetes and periodontal disease have what we call a “bi-directional” relationship.

Simply put, in one direction, diabetes contributes to an inflammatory environment within the oral cavity and an exaggerated, destructive host response. In the other direction, the infectious process of periodontal disease, coupled with pervasive inflammation, can make glycemic control more difficult.

2) As diabetes educators, what questions can we ask the patient to find out about their oral health status? What should we include in our visual assessment?

The patient health history, or interview should include the following questions:

• When was the last time you visited the dental office for a cleaning?
• Do your gums generally bleed when you brush?
• Have you ever been told that you have “gingivitis”, or “gum disease?”
• Have you noticed any areas on your gums that get red, or swell?
• Do you notice, or have others noticed, that your breath has a consistently foul odor?
• Have you noticed any looseness or shifting of your teeth?
• Have you had dental extractions in the past?
• Have your parents or your siblings lost teeth because of gum disease?

    As part of a visual assessment, look for:

• Missing teeth, teeth with obvious tooth decay (disruption of the enamel surface with staining), dry mouth, raspberry-red tongue surface with yellowish-white patches, generalized exposed root surfaces of teeth, and mobile teeth. These findings indicate need for prompt dental referral.

3) What steps can patients take to maintain oral health?

Promote Preventive Oral Care/Maintenance includes:

• Professional Dental Hygiene visits with periodontal probing every 3 – 6 months.
• Brushing with soft toothbrush at least twice per day using a triclosan/copolymer-containing toothpaste (Colgate Total).
• Flossing- at least once daily.
• Antimicrobials, when necessary via sub gingival or systemic delivery.

4) If a patient has gum disease and diabetes, what steps can we take?

 As with any disease, the goal is to treat gum disease early, when gingivitis is first discovered.  More often than not gingivitis is reversible, with a dental cleaning, good oral hygiene instruction, and thorough homecare.

Periodontitis results when continued inflammation leads to detachment of the epithelial junction beneath the gum (pocketing) resulting in resorption of the alveolar bone supporting the teeth.

5). For patients who have no dental insurance, what are resources we can provide?

Unfortunately, for patients without dental insurance, resources are limited. Medicaid dental providers are rare and Medicaid coverage for necessary treatment is limited. State and local dental societies, as well as private dental providers, will generously offer free dental treatment for indigent patients in need of dental treatment. The Florida Dental Association for example, has an “Access To Care Resource Guide” on their website floridadental.org

6.  What is YOUR one take home message regarding diabetes and oral health that we can pass on to our patients and community?
Be diligent about your daily oral healthcare regimen and don’t underestimate the importance of visiting your dental healthcare professional, at minimum, every 6 months. A significant number of people with diabetes have moderately inflamed (or worse) gum tissue and will require visits every 3 months.
In addition, elevated blood sugars cause dry mouth and increase the amount of sugar in the saliva. Both of which can contribute to worsening gum disease, tooth decay and thrush.

The bi-directional relationship of periodontal disease and diabetes make regular and effective dental care absolutely essential.

Bottom line:  Glycemic control improves oral health and good oral health improves glycemic control.

7.   Any website resources you recommend?

• The American Dental Association has a patient information website: mouthhealthy.org
• The American Academy of Periodontology has a patient information page: perio.org
• State and local dental societies have patient information websites; i.e., The Florida Dental Association (floridadental.org).
• Diagnosing Diabetes at the Dentist – Medscape Article

Special thanks to our guest contributor, Jerry A. Brown DMD, CDCES who is the first, and currently, the only dentist who is a CDCES! Dr. Brown lives in Florida and spent nearly three years volunteering at the University of South Florida’s Diabetes Center. He is a member of the American Diabetes Association’s Advocacy Committee and Community Leadership Board. He’s lived with diabetes for 45 years.

In our Ask an Expert series, Beverly Thomassian answers commonly asked patient questions.

Help! I’m an over-corrector
Anytime I have a blood sugar low, I take it as license to eat. Muffins, chocolate, pizza—you name it. As a result, I gained 8 pounds last year! How can I tame this habit?

First, if you are getting low blood sugars a few times a month, it could be a sign you are taking more diabetes medication than you need. Talk to your provider about decreasing your diabetes medication dose. If that’s not the case, then try and follow the 15 -15 rule: If your blood sugar is less than 70, try to limit yourself to only eating 15 grams of carbohydrate and then recheck blood sugar in 15 minutes and if still below 70, eat 15 more grams. Have preplanned 15 gram carb snacks easily available such as; small box of raisins, an apple, a 6oz juice box.

Guilty and down in the dumps
Type 2 diabetes runs in my family. For the last two years, my doctor has told me to lose 25 pounds because my blood sugars put me in the pre-diabetes range. Well, now I have full-blown type 2. I feel guilty and depressed. How can I find the motivation to do what I need to do?

Start by giving yourself permission to let go of the past. Be encouraged that even though you have diabetes, you can still have a healthy life. Starting today, write a list of what brings you joy in your life. This “joy list” can be used to light your spark of motivation and encourage small changes in your activity level and eating habits. Commit to making one change that you can realistically accomplish. For example, “I will drink water instead of soda” or “I will get up and move every hour”. Also meeting with a diabetes educator or attending a support group can be very helpful.

Confused about “good” and “bad” foods
I’m newly diagnosed with type 2 and confused: I thought I would have to cut out sugar. But my diabetes educator tells me no foods are off limits. Isn’t the sugar in foods making by blood sugar levels high?

Yes, you can eat foods with sugar, you just have watch portion sizes and not eat too much at one time – a strategy called “carb counting”. Many starchy foods are healthy and are full of nutrients and fiber, even though they are broken down to sugar in your blood. These include fruits, whole grains, milk, beans and starchy vegetables (potatoes, corn etc.). Other carb sources such as desert and snack foods, offer less nutritional value, so they would be considered a special treat to enjoy on occasion. And if possible, avoid sugary drinks and sodas to help with weight and blood sugar control.

F.A.S.T. is an easy way to remember the sudden signs of stroke. When you can spot the signs, you’ll know that you need to call 9-1-1 for help right away. F.A.S.T. is:

Download Infographic on Stroke and App here >>

F	Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person’s smile uneven?
A	Arm Weakness – Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward?
S	Speech Difficulty – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like “The sky is blue.” Is the sentence repeated correctly?
T	Time to call 9-1-1 – If someone shows any of these symptoms, even if the symptoms go away, call 9-1-1 and get the person to the hospital immediately. Check the time so you’ll know when the first symptoms appeared.

Beyond F.A.S.T. – Other Symptoms

• Sudden NUMBNESS or weakness of face, arm, or leg, especially on one side of the body
   
• Sudden CONFUSION, trouble speaking or understanding speech
   
• Sudden TROUBLE SEEING in one or both eyes
   
• Sudden TROUBLE WALKING, dizziness, loss of balance or coordination
   
• Sudden SEVERE HEADACHE with no known cause

 

April 27, 2016 started out as a usual morning. Rushing to get the kids ready for school, preparing breakfast and writing my to-do list for the day.

That’s when I noticed something was wrong.  I kept trying to write my list, but the words on the paper did not match the words in my head. I gave up on that project and moved on to talking to the kids, making sure they were ready for school. But, I couldn’t assign the right words to my instructions. I called bread, butter. I couldn’t remember the word for egg.  I stuttered. Then I started crying and said, “I think I am having a stroke”. 

My 14-year-old son Robert, jumped up, got the phone and called my husband, a pharmacist who works at a nearby hospital and stroke center.  My husband, Chris, frantically told Robert to, ‘call 911 and get your mom to the hospital NOW”.

I grabbed the phone from Robert and reassured my husband that I was fine and I did not need an ambulance. I hung up and hurried my 3 kids into the car, worried they would be late for school. As I drove them to their 3 different destinations, I tried retelling them news events that had happened earlier that day, to prove to them I was fine.  

After all, I was only 52 and super healthy.

During that 20-minute kid drop of route, my husband called me at least 6 times. He kept commanding that I come to the hospital NOW. The entire stroke team was waiting for me.  

I finally relented and at 8:47am on a blue sky Wednesday morning, I was in the ER.  The stroke team started their familiar choreography. They rushed me into a gown, hooked up monitors, drew blood and laid me on the gurney for a CT Scan of the brain. The results came back fast. No bleeding in the brain, it was a non-hemorrhagic event and I had no lingering stroke symptoms. 

So Tissue Plasminogen Activator (TPA) was not indicated.  TPA a clot buster that is administered to non-hemorrhagic stroke patients within 3 hours of stroke symptoms.  I was not the right candidate for this intervention since most of my stroke symptoms had resolved.

Three hours after the event, I was ready to go home. Convinced this was all a mist­­­­ake since my CT scan, labs and heart rhythm looked good. Why should I waste precious hospital resources with an overnight stay?

The team insisted I stay and wait for the results of the MRI of my brain that was scheduled for the next morning.

I spent the night in the hospital, getting neuro checks every 4 hours, playing with the controls on my bed, keeping a brave face when I told shocked family members and friends of the series of events.

Truth be told, for the past 30 years I had been fighting for my life and my health. My dad suffered a  a heart attack at 39 and a stroke at 44.

Me and my dad, pictured here, months before his death at 56 from a massive heart attack.

His shortened life was a central motivating force for my healthy lifestyle.

To maintain my best health, I was clocking 55 miles a week of walking, dancing two hours a week, and eating a diet filled with vegetables, fruit, fiber and an occasional glass of red wine.  My lifestyle habits put me at low risk for stroke, but my genetics worked against me.  Because of my dad’s stroke history, my risk of stroke was triple that of the general population.

The next morning, I was up at 6:30 am and mentally ready to go home.  I decided to try some dance choreography in my room to see if I could remember the sequence of moves.  It went well except for a few balance issues. I put on some mascara and wrapped my hair into a bun with two bobby pins that I found at the bottom of my purse. To show everyone I was going to be okay, I clipped on a big fuchsia flower right above my ear.

At 11 a.m. I was rolled into the noisy, rhythmic banging tunnel of the MRI machine. I imagined the magnetic energy exploring the nooks, crannies and undulations of my white matter, searching for injured brain tissue. An exploration that I was sure, would turn up empty handed.

At 12:40 p.m., the neurologist walked into the room saying he had read the results of my MRI and that I had suffered a stroke in the Wernicke center of my brain.  What he said after that, I don’t remember.

He left the room and the tears started pouring from my eyes. The nurse walked in and just sat with me as I shared the news. My husband, who was working in the hospital, flew into the room, breathless from running up three flights of stairs after I texted him to “please come”. He saw my distress and wrapped me in his arms. He whispered a sweet prayer in Armenian, blessing me and asking for Gods healing powers.

Since that day, I feel like I am a slightly different version of myself.  If you met me on the street or at a conference, you probably would have no clue of my stroke history. And, according to my family, I am pretty much still the same.

The MRI revealed the stroke was located in the Wernecke center, this is an area in the brain responsible for understating words and speaking them in a logical sequence. Fortunately, it is considered a very plastic area of the brain, so that other parts of the brain can compensate for its deficits.

The neurologist explained that I had suffered an ischemic stroke and would need to be on medications (aspirin, Plavix and Lipitor) to prevent another stroke. As I learned during my hospital stay:

There are 3 main types of stroke:

• Ischemic stroke – this occurs due to an obstruction in a brain blood vessel
• Hemorrhagic stroke – when a weakened blood vessel ruptures
• Transient Ischemic attack – caused by a temporary clot

Most of the time, the cause of the stroke can be identified.

However, thirty percent of the time, the cause is not known. This is called a cryptogenic stroke. In cryptogenic stroke, possible culprits include atrial fibrillation, clotting issues, heart malformations, and other inflammatory states. This is the type of stroke I had. For this reason, they will do long term heart monitoring to see if I have silent a-fibrillation and if it is positive, they will need to start me on a Coumadin-like therapy.

In either case, a person who has had a stroke has a 14 to 25% of recurrence within 2 years. To prevent the second event, there is a BIG focus on risk reduction (see below).

The good news is, I feel great. In spite of chronic painful neuropathy in my right foot and leg secondary to the stroke (a rare post stroke phenomenon called central pain syndrome)  I still work and walk for 3-4 hours a day on my treadmill desk. Sometimes, I have to work a little harder to remember words or say them right. And on occasion I will say a word that doesn’t yet exist. And sometimes I think I express myself even better.

Maybe this was my stroke of luck – An early warning sign that forced me to take action to prevent a more debilitating stroke.  This event gives me the opportunity to make sure I am doing everything possible to keep healthy through lifestyle and the right medications. After all, my dad had his first stroke at 44 and I didn’t have mine until 52. So maybe all the years I have worked hard to keep healthy have paid off.

Maybe this stroke provided me with a window to share my story with you and my diabetes community to increase awareness and early intervention.

You will be happy to know, I just got back from a one-week beach vacation with my husband and boys. I had no problem playing football with them, kayaking in the ocean, challenging my husband to a push-up competition and writing this newsletter.

 My 14-year-old son wrote me the most touching Birthday Card a few weeks after my stroke. In it he said,

“Mom, you taught me that it’s not what happens to you,
but how you bounce back”.

I love this quote by Anna Quindlen, “The thing that is really hard, and really amazing, is giving up on being perfect and beginning the work of becoming yourself.”  I am excited to start on this new journey and thankful for this stroke of luck. 

Here is some more info on Signs of Stroke to share with your community!

Diabetes Nurse Specialist Beverly Thomassian provides some answers to commonly asked care questions.

I love fruit, but I’m confused about if it’s okay for me to eat it. It has a lot of sugar and it is a carb. What’s the story?

Fruits contain a natural sugar called fructose, which can raise blood sugars like any other foods containing carbohydrates. But, this doesn’t mean fruits are off limits. We recommend that people with diabetes eat 3 to 4 fruit servings, spread throughout the day. Fruits provide natural energy, fiber, nutrients and support good gut health, plus they are fat free. Here are some examples of one serving of fruit: Small baseball size apple, orange or peach or other stone fruit, 1 ¼ cup strawberries or watermelon, 3 apricots, ½ cup canned fruit, ¾ cup of berries, ½ banana. So enjoy fruit; a completely natural food that nourishes your body.

Sometimes I feel wobbly on my feet, and it’s hard to walk. Could this have anything to do with my diabetes, and if so, what can I do about it?

Balance is a big issue for people living with diabetes, since it can lead to a fall, bone fracture or other problems. There are several potential causes for wobbliness that you can bring up with your provider for evaluation. First, there may be nerve damage to your feet, causing numbness which can make you feel unsteady. Another common cause associated with aging, is the loss of muscle mass and sense of balance. This is more likely to be true in people who sit for long periods of time and don’t move much. The good news is that by becoming more active and doing specific exercises designed for balance, many people feel less wobbly on their feet.

I have type 2 diabetes, I’m a woman, and I weigh 225 pounds. I know I have to lose at least 75 pounds, so why does my doctor say that losing just 5% will help a lot? That’s only about 12 pounds!

There are many studies looking at people living with type 2 diabetes that clearly demonstrate that losing 5-7% of your body weight (no matter how overweight you are) helps your cells respond better to your body’s own insulin and lower blood sugars. When people lose weight, about 30-50% of that weight loss is from the belly fat. This is important, because belly fat releases chemicals that stop insulin from working effectively. Just a 5-7% weight loss burns enough belly fat to make your body’s own insulin work better and help your muscle use sugar for energy. Which translates into lower blood sugars.

My diabetes medications are getting so expensive, but I’m embarrassed to talk with my doctor or diabetes educator about it. Do you have any suggestions?

Many people, like you, are struggling with expensive medication co-pays that are outside their budget. I encourage to ask your pharmacist to see if there are generic or less expensive versions of the medications you are taking. Contact your insurance company and ask if there are any medications in the same “class” that would be less expensive. After doing this research, you can bring the information to your team of providers and/or educators and ask for their help in problem solving. Be reassured, that they want to help you get the medications you need to stay heathy.

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