How can diabetes affect the brain and psyche?

Diabetes places daily demands on the people affected. Many of those affected suffer because that the disease determines their everyday lives. This is coupled with the fear of complications. The constant demands can become a permanent emotional burden and place the patient in a state of constant stress. This is known by specialists as “diabetes distress.”

Chronic stress causes the body to produce increased levels of the hormone cortisol. Cortisol increases the blood sugar level in order to provide the body with more energy quickly and when needed. At the same time, high stress levels stimulate the release of the appetite hormone ghrelin. This appetite hormone promotes the desire for sweets and carbohydrate-rich foods, making the blood sugar levels likely to rise even further due to the increased food intake.

A number of investigations have shown that diabetes distress often leads to the patient taking less care of themselves. Sooner or later, this affects the success of the treatment. If diabetes is neglected, metabolic control deteriorates, and the risk of long-term complication increases.

The good news: There are many learnable methods and measures to help reduce distress. It is critical to seek and accept help. Psychology refers to strategies for coping with stress as “coping strategies.”

Concerns, worries, and fears related to diabetes can be emotionally overwhelming. A number of studies have confirmed that people with diabetes more often report anxiety and are twice as likely to show signs of depression as people of the same age with a healthy metabolism. It is estimated that 10 percent of people (10 out of 100 persons) with diabetes are afflicted with “true” depression and approx. 25 percent (25 out of 100 persons) suffer from depressed moods. Overall, women with diabetes more frequently suffer from depression than men.

Patients often become less motivated to implement their diabetes treatment when suffering from depressed moods or depression. Neglected treatment results in increased blood sugar levels. This is compounded by the fact that the stress hormones associated with psychological stress negatively influence the blood sugar levels. Long-term elevated blood sugar levels increase the risk of suffering from the complications of diabetes affecting the blood vessels, heart, eyes, kidneys, and nerves. Consistent treatment of depression can help improve the metabolic state associated with diabetes.

Depression or depressed mood?

Not every dejected emotional state is automatically depression or depressed mood. Temporarily feeling dejected or sad is a normal part of life. However, when the feeling of dejection persists over a longer period of time, i.e., several weeks or months, depression may be the underlying cause. Depression is often underestimated and kept secret by those affected.

Questionnaires can help patients and their treating physicians to identify an existing case of depression. This is important because people affected by depression require therapeutic help. When depression is diagnosed, if necessary, the doctor can refer the patient to a psychologist or psychotherapist. The drug-based treatment of depressive disorders is also possible.

Specialists refer to depressed mood when symptoms such as dejection, increased need for sleep, constant fatigue, and lack of motivation are evident for a limited time period (less than 14 days, for example). The symptoms of depressed mood are also milder than those of depression. Also, compared to depression, it passes without therapeutic help. Nevertheless, it can be beneficial for those affected to seek help in coping with their low mood.

Typical signs of depression include, for example, persistent

• Sadness
• Lack of motivation, inner restlessness
• Difficulty thinking and concentrating
• Feelings of guilt and inferiority
• Loss of interest, listlessness
• Feelings of anxiety
• Sleep disorders
• Loss of appetite
• Deep despair, suicidal thoughts

Blood sugar levels which are elevated over a longer period of time can damage the larger and smaller blood vessels in the body and thus affect various organ systems. The risk of cardiovascular diseases increases; for example, high blood pressure, heart attacks or strokes are more likely to occur than in people with a healthy metabolism.

Damage to the blood vessels that supply the nerves with oxygen and nutrients result in nerve damage that can develop into what is called polyneuropathy.

Damaged nerve cells in the brain can impair the power of concentration and memory performance of those affected. In the long term, they can result in dementia.

Diabetes and dementia

There are many potential causes of increasing forgetfulness or difficulty concentrating. There is not always a serious underlying condition in these cases. Everyone has experienced suddenly not being able to recall a name or simply forgetting an appointment. However, when episodes of impaired memory become more frequent, this can indicate the early signs of dementia. Dementia affects the ability to retain and recall information and is especially noticeable with regard to short-term memory. Patients with advanced dementia are often unable to recall the current year, month, or day. In some cases, they even forget their own name or birthday. Changes in personality, states of confusion, and orientation problems are also common. It can become so severe that those affected are unable to find their way around their own living space.

Dementia is a collective term for around 50 different forms of mental impairment with various causes and varying progression. The most common form is Alzheimer’s dementia. Other clinical pictures include:

• Vascular dementia, which is caused by circulatory disorders in the brain
• Frontotemporal dementia, which causes nerve cells in the frontal area of the brain to die off
• Lewy body dementia, which is similar to Alzheimer’s dementia but is associated with a different type of proteins that are deposited in the brain

If mental impairment is suspected, simple cognitive tests can be carried out as a first step in the GP practice. Medical professionals can use these tests to distinguish changes in thinking and memory from age-related limitations. They also provide an initial indication of the type of dementia. As the disease progresses, the tests are also used to monitor the course of the disease.

Many clinics have outpatient memory clinics or memory consultation hours for further examinations. Once the suspicion of dementia has been confirmed, various physical examinations are usually carried out to narrow down the cause more precisely. The examinations include imaging procedures or the examination of the cerebrospinal fluid, which surrounds the brain and spinal cord.

People with diabetes more frequently have impaired cognitive function and are at greater risk of developing dementia than people with a healthy metabolism. People with diabetes are twice as likely to develop dementia during their lifetime as a person of the same age without diabetes. The good news: There are many ways to reduce the risk of developing dementia – including and especially for people with diabetes.

Specialists assume that there are several causes of the elevated risk of dementia associated with diabetes. These include poor management of blood sugar, blood pressure, and blood lipids, smoking, lack of physical activity, obesity and/or depression.

Alongside elevated blood sugar levels, severely low blood sugar levels can also promote the onset of dementia. Study data shows that 3 or more cases of severely low blood sugar levels double the risk of later suffering dementia.

Alzheimer’s disease is a subtype of dementia. In the brains of people with Alzheimer's disease, typical protein deposits (beta-amyloid plaques) and a maldistribution of tau proteins in the nerve cells can be observed. Both of these observations are deemed to correlate to damage to the brain cells.

The typical proteins can be detected in the cerebrospinal fluid. Alzheimer's disease can be proven beyond doubt by examining the cerebrospinal fluid (CSF).

Alzheimer’s disease causes a slow and progressive deterioration of nerve cells and neuronal connections. As increasing numbers of nerve cell begin to die off, mental faculties are lost. This eventually results in memory loss. The character of those affected can also change, as not only thinking capacity but also their emotional and social skills become ever more impaired.

It has been known for many years that the risk of developing Alzheimer's disease is almost twice as high for people with diabetes compared to people with a healthy metabolism.

The good news: A healthy lifestyle with a balanced diet and sufficient physical activity helps to prevent both conditions at the same time. Read here what you can do to reduce your risk of type 2 diabetes and other non-communicable diseases.

Diabetes is associated with an increased risk of eating disorders. Binge eating disorder plays a role particularly in type 2 diabetes. This is a serious mental illness that needs to be treated.

In the case of type 1 diabetes insulin administration is sometimes intentionally skipped to promote weight loss. This is known as insulin purging. The resulting rise in blood sugar levels can lead to serious long-term health risks and complications. There is also a risk of diabetic ketoacidosis, a life-threatening complication of diabetes.

A further type of eating disorder is bulimia (bulimia nervosa), that involves binge eating followed by vomiting or the use of laxatives. Above all, it is observed in adolescent girls with type 1 diabetes.

Risk factors for the onset of eating disorders in patients with diabetes include:

• a younger age;
• being female;
• heavier body weight;
• dissatisfaction with body image; and/or
• depression.

Many of those affected tend to deny or trivialize their eating disorder.

Eating disorders must be seen as a disease. The consequence of eating disorders in people with diabetes is an increased risk of diabetic emergencies in the short term, such as diabetic ketoacidosis, and poor blood sugar management in the long term, associated with a higher risk of complications, such as nephropathy, retinopathy, or cardiovascular disease. Therefore, the earlier professional help is sought to treat an eating disorder, the better.

Binge eating disorder: Not having eating behavior under control

Recurring “attacks” of excessive eating are typical for binge eating disorder. It usually affects people with type 2 diabetes who have lost control over their eating behavior, causing them to eat excessive amounts in a short period of time. They usually do this secretly and irrespective of any feeling of hunger. Unlike bulimia, people with binge eating disorder do not try to throw up the food they have eaten in order to counteract weight gain.

A similar clinical picture is what is called night eating syndrome which is associated with uncontrollable eating at night.

Binge eating disorder occurs more frequently in the general population than anorexia or bulimia. On average, around 28 out of every 1,000 girls and women will develop a binge eating disorder during their lifetime. Male adolescents or men are affected much less frequently – on average around 10 out of 1,000.

Studies show that eating disorders are significantly more common in people with diabetes – both type 1 and type 2 diabetes – than in people without diabetes. Around 230 out of 1,000 persons with diabetes have a binge eating disorder.

People with a binge eating disorder are more likely to develop overweight or obesity. This in turn is associated with deteriorating blood sugar levels and an increased risk of type 2 diabetes.

Insulin purging, also known as diabulimia, is most commonly seen in girls and young women with type 1 diabetes . Because insulin promotes weight gain, the required insulin doses are skipped. The discontinuation of insulin to achieve weight loss is dangerous. As the diabetes is basically being left untreated, this poses a serious risk of potentially life-threatening complications, such as diabetic ketoacidosis, which results in a severe build-up of acid in the body.

In the long term, diabetes-related damage to blood vessels and nerves can occur much earlier than in people with diabetes without an eating disorder.

Read more about the possible complications of diabetes here.