Always on My Mind: The Cognitive Burden of Type 2 Diabetes

by Bigfoot Biomedical,
May 29, 2019


To the casual observer, a day in the life of a person with insulin-requiring type 2 diabetes can appear quite calm and manageable. But like a duck gliding across a still lake, there’s a lot going on below the surface.

The day begins with a finger stick, making a finger bleed so that we can check our blood glucose level. That number sets in motion a stream of questions and decisions.

Are we seeing the after-effects of something we ate last night? Did we sleep well? What should we eat for breakfast? Are the ingredients on hand? Is there time to make breakfast? What if we just crawled back into bed? Stress? Anxiety? Overwhelm? What to call this sensation? Exercise today would be a good thing. Is there time to go to the gym? Do an exercise tape? Take a walk? Take the stairs?

And, oh yeah, how much insulin are we taking this morning? Do we have to calculate the dose? Or is it a predetermined amount? Is this shot a mix or a single kind of insulin? Which kind of insulin?

As we stand in front of the bathroom mirror with a needle poking into our abdomen, pushing down the plunger on the pen or syringe, the flood of thoughts, sensations, and feelings continue.

What’s on the calendar for today? Are our diabetes supplies for the day packed up and ready to go? Or do we need to put them together before we can leave the house? Are we going anywhere new today? Do we need to scout out where and when we can discreetly take our lunchtime shot? What’s that tingling we feel? Is it in the soles of our feet? Could it be an itch or is something more serious developing?

We’re not even fully dressed and already we’ve considered at least a dozen possibilities. And we’ve worked to stay calm in the face of at least half-a-dozen situations that could undermine our diabetes management routine at some point today. Maybe we’re feeling uneasy. A little bit of bothered. Or would we call it dread? Take a deep breath. Here we go. The day has barely begun.

Less than five minutes has passed. To the outside viewer, we’ve done two things: We’ve measured our blood glucose level and administered a shot of insulin. Inside our head, it hasn’t been quite that simple or clear cut.

Imagine starting your day like this. Every day. For the rest of your life.

It’s not “all in your head.” The mental and emotional burden of continually managing diabetes takes a toll on our health, both physical and mental. Overwhelm and frustration can be constant companions. There are a lot of labels used to describe what we experience: Stress. Anxiety. Depression. Burnout. Diabetes-related distress. Pick your favorite.

We start each day knowing what we’re supposed to do to manage diabetes—keep our glucose levels in range. And if we can’t do that, then don’t let our glucose levels get too high or too low for too long, or too often.

We gather the tools and medications we need—at least the ones we can afford. We plan our day. And, as much as possible, we follow our health routine. But there’s always the possibility that something unanticipated will derail our efforts.

Even with all this preparation and continual attention, many of us end each day concerned that our best efforts may not reliably keep us in-range and the actual results of our efforts are mostly unknown.

Forty-two factors have been identified as affecting glucose levels. They include puberty, periods, feeling stressed, and altitude.

How often is too often to be out-of-range? How long is too long? No one can tell us at what point damage may be done. No one can tell us when the damage done becomes permanent.

We’re frequently reminded that the consequences of failing to stay in-range are serious as death—literally. Type 2 diabetes could shave 10 years off our life. Along the way, if poorly managed, diabetes could also cause heart problems, kidney failure, blindness, or limb amputation.

We live every single day of our lives knowing that, and that can be hard.

Is it any wonder that some people living with type 2 diabetes may lose their motivation to maintain a healthy routine? That they question whether taking care of their diabetes is worthwhile? Or that they doubt the impact of their efforts, especially in the face of obstacles like access and costs?

Burnout seems inevitable.

A number of studies document the association between diabetes and reduced health-related quality of life (HRQoL).

When people with diabetes type 2 diabetes were surveyed as part of the Diabetes Attitudes, Wishes and Needs (DAWN) study, 41% reported experiencing poor psychological well-being.

But this number may dramatically understate the impact diabetes is actually having on people.

The same study reported that healthcare professionals (nurses, primary care physicians, and specialists) estimated that between 62% and 72% of their patients with type 2 diabetes exhibited psychological problems, including depression, anxiety, stress, and burnout.

Over time, things may not get much better.

When the Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes (SHIELD) checked back in with its subjects after five years, it found that the HRQoL of people with type 2 diabetes was impaired. Perhaps more damning, researchers found that the HRQoL for people with type 2 diabetes had worsened to “a significantly greater degree” compared to the results for adults not affected by diabetes.

Sometimes it’s the diabetes medications themselves that cause our diabetes management to go haywire. Some medications can cause hypoglycemia, resulting in dangerously low glucose levels.

Hypos can happen really quickly. Within minutes, we can go from feeling a little dizzy, to sweating, to shaking. All the while, we know that, if a hypo goes untreated, it can lead to seizures, passing out, and even death. That is, as long as we aren’t hypo unaware.

Any time a hypo happens, the effects can be long lasting. The SHIELD study documents that people with type 2 diabetes who had experienced at least one hypo in the past 12 months demonstrate significantly worse physical and mental health than those who hadn’t experienced a hypo.

The impact of hypos goes beyond mood. The US National Health and Wellness Survey (NHWS) documented that hypos interfere with social activities, lead to missed work, are associated with presenteeism (being present but not fully productive) and undermine overall work productivity.

So as people with diabetes, we often fear getting caught in the downward spiral. Feeling anxious and depressed. Wondering if our efforts to take care of ourselves matter. Drained of physical and mental energy, every task becomes a challenge. But then, somehow, we find it in ourselves to continue.

We take small steps, deep breaths, and pack up our supplies for the day. We seek joy from all of the things in our lives that are NOT diabetes—our families, our careers, our activities we enjoy. And we look for peer support from friends and family and we ask about assistance programs and copay cards.

Our lives are so much more than diabetes, and they have to be, but this is what goes on inside the heads of many people living with insulin-requiring type 2 diabetes. Each and every day. And oh, by the way, we haven’t even gotten out the front door to start our day yet.

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