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Type 2 diabetes mellitus and psychological stress — a modifiable risk factor

Key Points

  • Psychological stress mobilizes biological responses implicated in type 2 diabetes mellitus (T2DM), including the release of glucose and lipids into the circulation, inflammatory cytokine expression and increased blood pressure

  • Repeated or sustained stress exposure leads to chronic allostatic load, with dysregulation of glucose metabolism and neuroendocrine function and chronic low grade inflammation. Dysregulation of the diurnal profile of cortisol release predicts incident T2DM in population studies

  • Epidemiological studies implicate depression, chronic work stress and early life adversity as risk factors for T2DM

  • The adverse effect of psychological stress on health behaviours such as food choice, physical activity and adherence to medication also contributes to T2DM risk

  • Among individuals with established diabetes mellitus, depression and diabetes mellitus-related distress are associated with poor glycaemic control and cardiovascular complications

  • Stress management interventions seem to alleviate stress symptoms in T2DM, but effects on disease progression have not been established

Abstract

Psychological stress is common in many physical illnesses and is increasingly recognized as a risk factor for disease onset and progression. An emerging body of literature suggests that stress has a role in the aetiology of type 2 diabetes mellitus (T2DM) both as a predictor of new onset T2DM and as a prognostic factor in people with existing T2DM. Here, we review the evidence linking T2DM and psychological stress. We highlight the physiological responses to stress that are probably related to T2DM, drawing on evidence from animal work, large epidemiological studies and human laboratory trials. We discuss population and clinical studies linking psychological and social stress factors with T2DM, and give an overview of intervention studies that have attempted to modify psychological or social factors to improve outcomes in people with T2DM.

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Figure 1: Overview of the human stress system.
Figure 2: Stress-related biological pathways and their effect on diabetes mellitus processes.
Figure 3: The diurnal pattern of cortisol output.

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Acknowledgements

The authors' work was supported by the British Heart Foundation (grant RG/10/005/28296).

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The authors contributed equally to all aspects of the preparation of this article

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Correspondence to Andrew Steptoe.

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Glossary

Psychological stress

A broad term referring to a range of psychological phenomena including exposure to external challenges (stress conditions in adult or earlier life), psychological distress (including depression and anxiety) and personal traits, such as anger or hostility.

Psychological distress

A measure that encompasses depressive symptoms, anxiety, general stress and sleep disturbance.

Diurnal cortisol pattern

The distinct pattern of daily cortisol output in humans.

Adipokines

An umbrella term for inflammatory factors expressed in adipose tissue.

The metabolic syndrome

A combination of factors (including central obesity, raised blood pressure and raised levels of cholesterol) that increases the risk of type 2 diabetes mellitus.

Self-care behaviours

In type 2 diabetes mellitus, these include behaviours such as glucose monitoring, managing complications and adhering to medication and lifestyle recommendations.

Collaborative care

A multidisciplinary form of management that can include a combination of lifestyle, pharmacological and psychological therapies, as well as patient education and regular practitioner monitoring.

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Hackett, R., Steptoe, A. Type 2 diabetes mellitus and psychological stress — a modifiable risk factor. Nat Rev Endocrinol 13, 547–560 (2017). https://doi.org/10.1038/nrendo.2017.64

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