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Cierra Lurz

Professor Flores

English 1201

1 May 2022

Repercussions of Type 1 Diabetes

Why do people with type 1 diabetes have a greater risk of developing mental health

issues? Type 1 diabetes is a chronic pancreatic autoimmune disease where the pancreas does not

produce any insulin, affecting blood sugar levels. This is oftentimes found in children, teenagers,

and young adults. It usually has a genetic predisposition, but genes do not always guarantee that

it is developed. It currently affects about 20 million individuals across the globe. It is frequently

confused with type 2 diabetes, which is when, instead of producing no insulin, the body either

does not produce enough of it or it simply resists it. Type 2 diabetes is developed over time and

is mostly found in adults. Diabetes management can be overwhelming and induce stress in many

people diagnosed with it. In some cases, this sometimes leads to mental health disorders. With

the responsibility of endocrinologist appointments, trying to maintain a healthy diet, exercising,

and controlling blood glucose levels, it is easy to see why someone would feel mentally drained

from all of it. Endocrinology is a branch of medicine focusing on the endocrine system, which

regulates metabolism and blood sugar, as well as many other things. The interface between

diabetes in general and mental illness has been a topic of discussion for years among

endocrinologists and psychologists. Today, there needs to be more attention paid to it. There is a

higher risk for an individual to develop mental health issues with type 1 diabetes than it is for

someone without because the long-term management of it can cause depression, diabetic distress,

and anxiety.
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One repeating point found in multiple sources is that depression is common in diabetics.

In “Diabetes and Mental Health” from the Centers for Disease Control and Prevention, the CDC

says that “people with diabetes are 2 to 3 times more prone to have depression than people

without diabetes” (CDC). The main goal of the CDC is to protect the nation by providing reliable

and factual health information regarding diseases, health threats, etc. Additionally, “Type 1

Diabetes and Depression” from JDRF (formally The Juvenile Diabetes Research Foundation),

mentions that “depression is estimated to affect one in four people with diabetes (type 1 and type

2)” (“Type 1 Diabetes and Depression”, 2020). The primary purpose of JDRF is to be a nonprofit

contributor to type 1 diabetes research. They have scientists responsible for conducting a myriad

of research tracks and have even successfully developed new technology and treatments for

those with type 1 diabetes. Another source, Mental Health, Diabetes and Endocrinology, a book

from Cambridge Core written by Anne M. Doherty, Aoife M. Egan, and Seán F. Dinneen states

that diabetics have twice “the risk of depression compared to the general public” (Doherty, Anne

M., and Seán F. Dinneen). With all of that being said, it has been made clear that diabetics are

more likely to have depression than those without diabetes. In fact, depression is one of the

leading causes of short-term and long-term complications in people with diabetes. Doherty and

others affirm that people suffering with diabetes and depression “are more likely to have poorer

outcomes” and have a harder time with “glycaemic control,” (Doherty, Anne M., and Seán F.

Dinneen). Diabetic neuropathy (nerve damage), foot damage, heart disease, and skin conditions

are just some of the most common complications that type 1 diabetics could have down the road

from constant high blood sugars.

Along with depression, some sources suggest that diabetes burnout is something that

almost every diabetic has experienced at one point or another. This can be different for everyone,
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but it is typically when one will stop taking care of their diabetes because they feel like it is a

burden to deal with. Doing so can result in major health problems like heart disease and nerve

damage and ultimately make the situation worse. A BBC News article titled “‘Diabetes Burnout’:

The Mental-Health Impact of Diagnosis” by Claire Kendall and Jeremy Cooke focuses on

Naomi, a woman who has lived with type 1 diabetes for over a decade. She claims that “she

reached a point where she simply could not handle "the physical or mental challenges of diabetes

any more", which is known as diabetes burnout to diabetics (Kendall and Cooke). Having to

constantly worry about insulin intake, calculations, unstable blood sugars, getting enough

exercise, and more can definitely take a toll on someone, especially since it is a daily battle.

Naomi realized how negatively it impacted her mental health. She “felt she could no longer bear

testing her blood sugar levels many times each day to calculate how much insulin she needed to

inject, even though she knew she was…putting herself in extreme danger” (Kendall and Cooke).

Being aware of the potential outcomes of not taking care of her diabetes did not affect the heavy

load on her shoulders. It still became a hardship for her after a while. “Unraveling the Concepts

of Distress, Burnout, and Depression in Type 1 Diabetes: A Scoping Review”, a journal by Dona

A. Kiriella and others, states that “diabetes burnout is characterized by feelings of mental,

emotional, as well as physical exhaustion of being affected with diabetes” (Kiriella, Dona A., et

al.). Not only does diabetes burnout have an effect on one physically, but it predominantly

affects one’s emotional and mental state as well. Not to mention the fact that it is recommended

for diabetics to check their blood sugar numerous times a day, which can be a difficult thing to

do if one is working or generally busy. The Mayo Clinic, a nonprofit clinic founded in

Rochester, Minnesota perpetrated to research, education, care, and clinical practice, mentions

that “The American Diabetes Association recommends testing blood sugar levels before meals
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and snacks, before bed, before exercising or driving, and if [one] suspect[s] [they] have low

blood sugar” (“Type 1 Diabetes - Diagnosis and Treatment”). This can be an exhausting and

time-consuming thing to do multiple times a day for diabetics, which is another solid reason why

diabetes burnout is so pervasive.

Similar to diabetes burnout, another key point made by many sources is the apprehension

and anxiety that can come along with this autoimmune disease. According to the CDC, “people

with diabetes are 20% more likely than those without diabetes to have anxiety at some point in

their life” because “managing a long-term condition like diabetes is a major source of anxiety for

some” (CDC). To add to that statistic, “How Diabetes Impacts Your Mental Health” from

Beyond Type 1, written by psychologist Mark Heyman who also specialized in diabetes, states

that “diabetes can be unpredictable and frustrating” (“How Diabetes Impacts Your Mental

Health”, 2016). Since diabetes can be a complicated thing to live with, it is difficult to know

exactly how to control and balance all of its aspects. Even doing the “correct” thing can create

poor results because there are so many variables that can affect blood glucose levels. For

example, the CDC says that “stress hormones make blood sugar rise or fall unpredictably, and

stress from being sick or injured can make your blood sugar go up” (CDC). A lot of type 1

diabetics are told to give themselves an extra unit or two of insulin when they’re sick so that it

can level out their blood sugars throughout the day. Diabetes is truly unpredictable and uncertain.

“As a Type 1 Diabetic, Including Carb Information on Menus Would Change My Life” from

The Independent written by type 1 diabetic Eleanor Noyce agrees, saying that “sleep, stress,

exercise, and, vitally, food” are all elements that affect blood sugar levels (Noyce). There are so

many factors that influence blood glucose levels, so it’s understandable why anxiety is apparent
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in so many type 1 diabetics, with the struggle and worry of getting as stable blood sugars as they

possibly can.

In addition to anxious thoughts and feelings, eating disorders are common in diabetics. In

Mental Health, Diabetes and Endocrinology there is a chapter that focuses on the coexistence of

diabetes and eating disorders in people titled “‘Diabulimia’, Diabetes and Eating Disorders”. It

says that diabetics with eating disorders have “higher incidence of diabetic complications and a

seven-fold increase in mortality” (Doherty, Anne M., and Seán F. Dinneen). Eating disorders are

psychological disorders where unhealthy disturbances in eating habits are involved. The two

most common and well-known eating disorders are anorexia nervosa and bulimia nervosa,

although there are many others that exist. Doherty, Egan, and Dinneen specifically mention that

“eating disorders and subthreshold eating disorders are significantly more prevalent in female

patients with type 1 diabetes compared to their peers without diabetes” (Doherty, Anne M., and

Seán F. Dinneen). This isn’t surprising, though, as “Gender Difference in the Prevalence of

Eating Disorder Symptoms” from The International Journal of Eating Disorders by Ruth H.

Striegel-Moore and others states that “epidemiological studies have shown that anorexia nervosa

(AN) and bulimia nervosa (BN) are more common among females than males” (Striegel-Moore,

Ruth H., et al.). They are not limited to just women, though. Anyone, regardless of age, gender,

race, etc. can develop an eating disorder. Furthermore, the behaviors found in individuals with

anorexia nervosa aren’t exactly the same as the behaviors found in those with both anorexia

nervosa and diabetes. “In particular, the practice of restricting insulin in order to achieve weight

loss has been found to be a common behaviour among women with diabetes” (Doherty, Anne

M., and Seán F. Dinneen). Obviously, people without diabetes do not have to worry about daily

insulin intake, so rather than restricting insulin, they restrict their food and calorie intake.
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Moreover, this is the same case with bulimia nervosa. People with bulimia nervosa have episodes

of purging after overeating by inducing vomiting, abusing the use of laxatives, etc. Purging, in

type 1 diabetics, “may also occur by insulin omission with resultant glycosuria, calorie loss and

an increased risk of ketoacidosis” (Doherty, Anne M., and Seán F. Dinneen). Along with the

common purging methods among those with bulimia nervosa, type 1 diabetics may also purge by

excessively restricting their required insulin doses in hopes of losing weight.

Overall, there is a high chance of diabetes and mental disorders having a two-way

relationship. Dating back to the nineteenth century, “London psychiatrist Henry Maudsley noted

that ‘diabetes is a disease which often shows itself in families in which insanity prevails’

(Doherty, Anne M., and Seán F. Dinneen). Maudsley believed that people who already had

mental disorders were more likely to develop diabetes. “In more recent years, the evolving

literature on the topic has not only made it evident that diabetes is more common among people

who have mental disorders but also shown that mental disorders are more common among

people living with diabetes, thyroid disease and obesity” (Doherty, Anne M., and Seán F.

Dinneen). This just further proves that mental disorders and diabetes go hand in hand with each

other and are found to be bidirectional. This is especially true for depression and diabetes.

According to Mental Health, Diabetes and Endocrinology, “there is evidence that the patients

with diabetes have an increased incidence of depression and patients with depression are at

increased risk of developing diabetes” (Doherty, Anne M., et al.). Fundamentally, diabetes and

depression have a reciprocal relationship, having the ability to mutually influence each other.

So how are diabetics able to manage their diabetes along with psychological stressors and

disorders? There are many mental obstacles that type 1 diabetics might encounter and don’t

receive support or treatment for. These may include “a fear of hypoglycaemia; a fear of needles;
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weight and shape concerns; or even a disabling fear of developing the end-stage complications of

diabetes, precipitating a state of denial” (Doherty, Anne M., and Seán F. Dinneen).

Hypoglycemia, also known as low blood sugar, is something every diabetic inevitably

experiences at one point or another. Some symptoms are shakiness, confusion, blurred vision,

unsteadiness, hunger, and fatigue. The Mayo Clinic explains the reasons why blood sugar levels

go down, “including skipping a meal, eating fewer carbohydrates than called for in [one’s] meal

plan, getting more physical activity than normal or injecting too much insulin” (“Type 1

Diabetes - Diagnosis and Treatment”). If not treated quickly enough, one could faint, have a

diabetic seizure, or lose consciousness. In worst-case scenarios, low blood sugars can even be a

risk factor for a coma or death. It is clear to see why one would be afraid of hypoglycemia.

Along with hypoglycemia, no diabetic wants to have hyperglycemia, which is high blood sugar.

With hyperglycemia, one might get a headache, extreme thirst, dry mouth, and the frequent urge

to urinate. In Jennifer Berry’s article “How Does High Blood Sugar (Hyperglycemia) Feel?”

from Medical News Today, she conveys that “High blood sugar and low insulin can lead to a rise

in ketones, and possibly diabetic ketoacidosis (DKA), a serious complication that needs urgent

medical attention” (Berry). This leads to another valid fear which is the fear of the possible

complications that diabetes could give someone if they don’t manage it the way they should and

keep their blood sugars stable, as mentioned on page 2. It is mentally draining to constantly

stress about these kinds of things, so “they can become targets for treatment, such as a cognitive

behavioural therapy (CBT) model of treatment. CBT models focus on examining the person’s

thoughts, feelings, physical sensations and behaviours, considering how they interact with one

another and working with the patient to find a more adaptive way of relating to their diabetes”

(Doherty, Anne M., et al.). Cognitive-behavioral therapy plus the professional diabetic advice
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from an endocrinologist could potentially be useful to type 1 diabetics and help positively impact

their mental state and give them the support and reassurance that they need.

Some might argue that type 1 diabetes is easily manageable and would not affect

someone’s mental health if they took care of it properly all the time as they should. This may be

true for many diabetics, but it is not as simple as it sounds, especially out in public. There is, to

say the least, a lot of hard work and dedication that gets put into it 24/7. Endocrinologists

encourage diabetics to always think ten steps ahead to be prepared for what their blood sugar will

do. This is easier said than done. For example, in restaurants, the carbohydrate count isn’t always

available on the menu, which leaves diabetics having to guesstimate. Eleanor Noyce says that

“listing carbohydrate information on restaurant menus would be life-changing” for her (Noyce).

Carbohydrates play a crucial role in determining insulin dosages. The more carbohydrates that

enter the body, the more insulin that is needed in order to hopefully bring the blood sugar down

to a normal level. The Mayo Clinic states that “generally, the goal is to keep [one’s] daytime

blood sugar levels before meals between 80 and 130 mg/dL (4.44 to 7.2 mmol/L) and [one’s]

after-meal numbers no higher than 180 mg/dL (10 mmol/L) two hours after eating” (“Type 1

Diabetes - Diagnosis and Treatment”). This is not always obtainable, especially in sit-down and

fast-food restaurants. Noyce says that “giving the incorrect dosage of insulin can either

“skyrocket” or “plummet” her blood glucose levels; she feels as though she “tread[s] a fine line”

(Noyce). As mentioned earlier, this can cause anxiety in diabetics, since they don’t know

whether to worry about if their next move is to find the next glucose tablet or juice box as

quickly as possible or if their blood sugar will be through the roof the next time they check it.

Therefore, if restaurants provided more nutritional information on their menus in person or

online, it would be less frustrating for diabetics.

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In addition to this, not everyone is able to afford the newly developed technology made

for diabetics such as continuous glucose monitoring devices (CGM) and insulin pumps, which

make checking blood glucose levels and receiving insulin doses a lot more efficient and fast.

Continuous glucose monitoring devices work to help type 1 and type 2 diabetics manage their

diabetes. A tiny sensor/needle inserted under the skin, usually the back of the arm or the belly,

measures glucose levels. A transmitter will send these levels to either a device or an app on one’s

smartphone. This makes it quicker and easier for diabetics to check their blood sugar. Plus,

continuous glucose monitors mean fewer finger stick tests and they “may be especially helpful

for preventing hypoglycemia” (“Type 1 Diabetes - Diagnosis and Treatment”). Insulin pumps, on

the other hand, are designed to provide continuous distribution of short-acting insulin throughout

the day to substitute the use of insulin injections. This also, most importantly, helps to improve

blood glucose levels, thus most likely improving mental health. The Mayo Clinic mentions that

while “research has found that in some people an insulin pump can be more effective at

controlling blood sugar levels than injections”, “many people achieve good blood sugar levels

with injections, too” (“Type 1 Diabetes - Diagnosis and Treatment”). Choosing to use/wear an

insulin pump device is all up to the person living with the disease. There is no right or wrong

method to receive insulin, as long as it is being taken. Although some might find the insulin

pump to be efficacious, many stick with needle or pen injections that get the job done equally as

much. Essentially, it is all just a preference of choice for every individual with type 1 diabetes

and it comes down to what works for them personally.

There are certainly some ways that endocrinologists advocate mental health to their

diabetic patients. Lisa Marie Basile’s “Hormonal Imbalances and Depression” from EW

discusses New York endocrinologist Dr. Rocio Salas-Whalen and what her thoughts are on the
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importance of her patients’ mental health. She says that she ensures that she “ask[s] them about

their moods” and most importantly if they “have a support system, and if they…want to be

referred to a therapist” (Basile). Dr. Salas-Whalen cares about her patients and genuinely

provides words of advice which should be done by every endocrinologist. Dr. Salas-Whalen also

tries her best to give solid advice for endocrinologists hoping to better understand their patients”

(Basile). She suggests talking and listening to the patient, as they always “[have] the answer”

(Basile). Dr. Salas-Whalen is a prime example to whom an endocrinologist should look up.

Normalizing the discussion of mental health in her experiences and appointments with patients is

a simple way for her to make progress in the future by encouraging other endocrinologists, and

doctors in general, to get their patients to open up emotionally/mentally. This also removes any

shame felt by people and it creates a safer space for them to speak about their thoughts and

feelings.

On a final note, it would be an understatement to say that people with type 1 diabetes

undergo countless physical and mental challenges. One might immediately think of only the

physical pain that comes with having this autoimmune disease, like getting insulin shots,

pricking fingers to test blood glucose levels, or having symptoms of hypoglycemia or

hyperglycemia. Type 1 diabetes is much more than just bodily pain. Individuals diagnosed with

type 1 diabetes are more prone to anxiety, depression, diabetic distress, and eating disorders than

someone without diabetes is. Until there is a cure, those who are type 1 diabetics will have to

withstand the long-term management of their disease. Therefore matters of this disease should

not be taken lightly as it is a difficult burden at times for someone to bear. It is a good idea not to

pressure or judge diabetics, as it can just make their thoughts and feelings worse, even if they do

not necessarily show it or let it be known. In the meantime, awareness should be raised on the
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topic of type 1 diabetes and how it can greatly affect one’s mental health so it can hopefully

make a difference in a diabetic’s life.

Works Cited

Basile, Lisa Marie. “Hormonal Imbalances and Depression.” EW, 3 June 2020,

https://www.endocrineweb.com/hormonal-imbalances-depression.

---. “How Endocrinologists Can Better Support Patients’ Mental Health.” EW Pro, 15 May 2020,

https://pro.endocrineweb.com/how-endocrinologists-can-better-support-patient-mental-

health.

Berry, Jennifer. “How Does High Blood Sugar (Hyperglycemia) Feel?” Medical News Today, 11

Mar. 2019, https://www.medicalnewstoday.com/articles/313138#causes.

CDC. “Diabetes and Mental Health.” Centers for Disease Control and Prevention, 7 May 2021,

https://www.cdc.gov/diabetes/managing/mental-health.html.

Doherty, Anne M., et al. Mental Health, Diabetes and Endocrinology. RCPsych Publications,

2021.

Doherty, Anne M., and Seán F. Dinneen. “Depression across Endocrine Disorders (Chapter 2) -

Mental Health, Diabetes and Endocrinology.” Cambridge Core,

https://www.cambridge.org/core/books/abs/mental-health-diabetes-and-endocrinology/

depression-across-endocrine-disorders/DE86E9A83DBA57A68A63062E8DBF2FE0.

Accessed 10 Apr. 2022.

“How Diabetes Impacts Your Mental Health.” Beyond Type 1, 12 Apr. 2016,

https://beyondtype1.org/diabetes-impacts-mental-health/.
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Kendall, By Claire, and Jeremy Cooke. “‘Diabetes Burnout’: The Mental-Health Impact of

Diagnosis.” BBC News, 16 Nov. 2020, https://www.bbc.com/news/education-54145335.

Kiriella, Dona A., et al. “Directory of Open Access Journals.” EClinicalMedicine, vol. 40.

Accessed 7 Apr. 2022.

Noyce, Eleanor. “As a Type 1 Diabetic, Including Carb Information on Menus Would Change

My Life.” The Independent, 14 Nov. 2021,

https://www.independent.co.uk/voices/restaurant-menu-diabetes-carbohydrates-dining-

b1957373.html.

Striegel-Moore, Ruth H., et al. “Gender Difference in the Prevalence of Eating Disorder

Symptoms.” The International Journal of Eating Disorders, vol. 42, no. 5, July 2009,

doi:10.1002/eat.20625.

“Type 1 Diabetes - Diagnosis and Treatment.” Mayo Clinic, 27 Mar. 2021,

https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/diagnosis-treatment/drc-

20353017.

“Type 1 Diabetes and Depression.” JDRF, 20 Jan. 2020,

https://www.jdrf.org/t1d-resources/living-with-t1d/mental-health/depression/.