Being diagnosed with diabetes is a life-changing event. Regardless of whether you have type 1 or type 2 diabetes, it forces you to make changes to your daily routine and take on a lot of new responsibilities.

Did I check my glucose levels? Have I calculated my carbohydrates correctly? Do I have my pen/pump, needles, fully-charged reader and glucose with me? Where and when will I get my diabetes supplies? Will I be able to pay for my insulin next month? When was the last time I saw my endocrinologist? Have I dealt with the insurance letter?

Am I doing this right?

Diabetes is a 24/7 job, and it never takes a day off. This takes a toll on the mental health of children and young people in particular. While their peers may seem to be moving through life with a carefree attitude, diabetes requires them to grow up at an early age and perhaps take on more responsibility than they are ready for. The statistics show the heavy psychological burden of diabetes:

• People with diabetes are at increased risk of depression, anxiety and eating disorders.[1]
• Depression rates across the lifespan are twice as high as in the general population.
• Eating disorders are twice as common in people with type 1 diabetes, with women most affected and bulimia nervosa the most common form.[2]

How can we promote mental health while living with diabetes?

Taking care of our mental wellbeing enables us to take better care of our physical needs, just as taking care of our physical body enables a healthy mind to flourish.

When it comes to wellbeing, we should first address our basic human needs: sleep and rest, hydration and nutrition, time spent outdoors and physical activity, as well as a sense of security, strong social ties and a sense of purpose.

A consistent daily routine can restore a sense of control and self-reliance. Psychotherapy, stress management skills and opening up to a friend or someone you trust can help ease the burden when diabetes becomes too stressful.

A diabetes team should always aim for holistic care, treating the person as a whole, and mental health screening should be part of regular check-ups. If needed, your doctor can refer you to a mental health care provider and find a support plan that meets your needs.

We are more than the sum of our parts. And as people with diabetes, we are more than our blood glucose levels. And whilst living with diabetes may feel overwhelming at times, remember that diabetes is part of your life, but there is more to your life than diabetes.

Thanks so much for reading and we’ll provide you with the next episode of this series soon!

[1] Fisher, L., Polonsky, W. H., Hessler, D. M., Masharani, U., Blumer, I., Peters, A. L.,. Bowyer, V. (2015). Understanding the sources of diabetes distress in adults with type 1 diabetes. Journal of Diabetes and Its Complications,29(4), 572-577.doi:10.1016/j.jdiacomp.2015.01.012

[2] Hanlan ME, Griffith J, Patel N, Jaser SS. Eating Disorders and Disordered Eating in Type 1 Diabetes: Prevalence, Screening, and Treatment Options. Curr Diab Rep. 2013 Sep 12:10.1007/s11892-013-0418-4. doi: 10.1007/s11892-013-0418-4. Epub ahead of print. PMID: 24022608; PMCID: PMC4002640.

We know that chronic high blood glucose can have serious long-term health consequences, but what happens when blood glucose rises extremely high in a short time? Hyperglycaemia can become an immediate, potentially fatal emergency. Here is what you need to know!

We divide hyperglycaemic emergencies into two forms: Diabetic Ketoacidosis (DKA) and Hyperosmolar Hyperglycaemic State (HHS). Their common element is an extremely high blood glucose level, and they differ in the presence of ketones. Ketones are an alternative source of energy for the body when it cannot use energy from sugar due to a lack of insulin. Both DKA and HHS usually occur in insulin-dependent people due to missed insulin injections, stress or infection.

1. Diabetic K etoacidosis: Keto – ketones, acidosis – acidification of the blood

DKA is characterised by very high blood glucose levels, usually 350 – 600 mg/dl, and high levels of ketones in blood and urine. Common symptoms are heavy breathing, diarrhea, vomiting, confusion and possibly unconsciousness. DKA typically affects people with type 1 diabetes, where a complete lack of insulin leads to high ketone production. Because ketones are dangerous in large amounts, the body tries to get rid of its toxic compounds (acetone) by exhaling them via the lungs – resulting in a fruity breath reminiscent of nail polish remover or alcohol. This is why people with DKA are often mistaken for passed-out drunks at night. Without immediate medical treatment, DKA can lead to severe dehydration, loss of consciousness or death.

2. Hyperosmolar Hyperglycaemic State

Hyperosmolar means that there is too much sugar (and other molecules) in the blood and not enough water to dilute it. In HHS we see extremely high levels of glucose, usually over 1000 mg/dl (55 mmol/L), but no ketones. HHS develops slowly over several days and occurs typically in people with type 2 diabetes, often older people. The first symptoms are often extreme thirst and dehydration, frequent urination and nausea. Warning signs of progression include confusion, loss of vision and eventually unconsciousness or coma.

Hyperglycemic Emergencies – Drunk or Diabetes?

As the brain is dependent on glucose for function, the first symptom of any disruption in glucose metabolism is often confusion or some change in mental status. When medical students ask, “Which patient should we do a glucose test on in the emergency room?“ A common response is: “Any funny patient!“ – referring to signs of confusion or odd behaviour when glucose metabolism has gone out of balance.

By looking out for these warning signs (confused, dehydrated, unconscious) in our environment, we can recognise hyperglycemic emergencies earlier and facilitate prompt, professional medical attention – and prevent dire consequences.

Thanks so much for reading and we’ll provide you with the next episode of this series soon!

1. Cardiovascular mortality

Managing diabetes is a daily struggle but is poses even greater risks and challenges for women. Generally, diabetes roughly doubles the risk for cardiovascular mortality, for women it is even a three-fold risk-increase. They are likely to have earlier heart attacks and are more likely to die from it.1 Due to differences in acute symptoms, women often don’t get the right treatment for severe cardiac events: While men may present with excruciating chest pain, women often display less obvious symptoms like neck- and abdominal pain, insomnia, and shortness of breath.

2. Reproductive health

Women with diabetes also face additional challenges related to their reproductive health. Conditions such as Polycystic Ovary Syndrome (PCOS), hormonal imbalances, impaired fertility, aggravation of menopausal symptoms and urinary tract infections (UTIs) occur all too frequently and can be a significant limitation in daily life.

3. Mental burden

Besides physical problems, the mental burden of diabetes weighs heavy. Stigma around weight and lifestyle in diabetes is highly prevalent and affects women more often than men. In gestational diabetes, women may experience stigma in the form of discrimination from health personnel, guilt and shame. While weight and lifestyle are important risk factors, gestational diabetes also occurs in metabolically healthy women, and these feelings of blame can be a heavy burden during this time.

4. Being criticised

Women also are more likely to feel criticized for their dietary choices and body weight, both in the media and personally. The recommendation to “just move more and eat better “, or questions such as „are you really allowed to eat that?“, can take on special significance in women. The constant preoccupation with food, weighing it, reading labels, rating its nutritional value, and classifying it into “good” and “bad” can be a major contributor to an unhealthy relationship with food. In female adolescents, eating disorders and weight dysphoria are particularly common and even more so in females with type 1 diabetes.

5. Sex disparities

It begins early on: a recent published systematic review showed that girls with T1D have higher BMIs, worse glycemic control, need higher insulin doses, more hospitalisations, and a lower quality of life, compared to their male counterparts.

So, what is needed to improve women’s health care in diabetes? One step is raising awareness and fostering understanding. But more than understanding, women and girls with diabetes need special attention from their physicians to their unique concerns: their physical symptoms, their mental health, and secure access to a tight support-network from various fields of health care.

Thanks so much for reading and we’ll provide you with the next episode of this series soon!

Norhammar A. Diabetes and cardiovascular mortality: the impact of sex. Lancet Diabetes Endocrinol. 2018 Jul;6(7):517-519. doi: 10.1016/S2213-8587(18)30111-6. Epub 2018 May 8. Erratum in: Lancet Diabetes Endocrinol. 2018 Jul;6(7):e6. PMID: 29752193.

Keteepe-Arachi T, Sharma S. Cardiovascular Disease in Women: Understanding Symptoms and Risk Factors. Eur Cardiol. 2017 Aug;12(1):10-13. doi: 10.15420/ecr.2016:32:1. PMID: 30416543; PMCID: PMC6206467.

Davidsen E, Maindal HT, Rod MH, Olesen K, Byrne M, Damm P, Nielsen KK. The stigma associated with gestational diabetes mellitus: A scoping review. EClinicalMedicine. 2022 Aug 11;52:101614. doi: 10.1016/j.eclinm.2022.101614. PMID: 35990581; PMCID: PMC9386490.

Striegel-Moore RH, Rosselli F, Perrin N, DeBar L, Wilson GT, May A, Kraemer HC. Gender difference in the prevalence of eating disorder symptoms. Int J Eat Disord. 2009 Jul;42(5):471-4. doi: 10.1002/eat.20625. PMID: 19107833; PMCID: PMC2696560.

de Vries, Silvia & Verheugt, Carianne & Mul, Dick & Nieuwdorp, Max & Sas, Theo. (2023). Do sex differences in paediatric type 1 diabetes care exist? A systematic review. Diabetologia. 66. 10.1007/s00125-022-05866-4.

When one thinks of diabetes, insulin automatically comes to mind, an important hormone for the human metabolism. But what is its function and, above all, what side effects does insulin have?

Besides lowering glucose being the main task for insulin, there’s more to it. While usually unnoticed, in type 1 diabetes, where insulin is missing, these side-functions become evident:

1. Cognitive function, learning, memory

Insulin has a key role in the hippocampus, a brain region that is highly involved in learning, memory and cognitive performance. Besides that it has regulating connections to the limbic system, where emotions, motivation, motor-action control and social behavior is controlled. An absence of insulin (and therefore glucose) leads to difficulties in memory, cognitive function and irritability. The higher the insulin sensitivity, the higher the cognitive performance indicators. [1]

2. Hunger and satiety

Physiologically, after a meal containing carbohydrates, insulin levels rise. As insulin passes the blood-brain-barrier, it acts as a strong feedback signal on satiety-centers (specifically, POMC-Neurons) in the hypothalamus. An absence of or resistance to this signal, as in T1/T2 diabetes, is interpreted by the brain as a shortage in nutrients and energy, thus leading to more appetite and initiating food seeking behavior. [2]

3. Tissue growth

Insulin is one of the most important anabolic, growth hormones. Especially muscles and bones, but also skin, hair and nails depend on the presence, and the right amount of insulin to grow. [3]

4. Fertility

Insulin acts on the female reproductive tract by regulating the production of estrogen and testosterone in hormone-producing cells on ovaries. High insulin levels can lead to high testosterone production, leading to symptoms of PCOS (irregular periods, masculine hair growth, acne). Also contributing to excess estrogen production, sore breasts, fibroids and heavy menses are typically associated with high levels of insulin. Conversely, the absence of insulin (as in T1D) is interpreted as a shortage in food-supply and in order to preserve energy, specific brain centers stop the production of cycle-regulating hormones, leading to irregular periods and infertility. [4][5][6]

Thanks so much for reading and we’ll provide you with the next episode of this series soon!

[1] Capucho AM, Chegão A, Martins FO, Vicente Miranda H, Conde SV. Dysmetabolism and Neurodegeneration: Trick or Treat? Nutrients. 2022; 14(7):1425. https://doi.org/10.3390/nu14071425

[2] S.M. Anika, T.R. Houpt, K.A. Houpt, Insulin as a satiety hormone, Physiology & Behavior, Volume 25, Issue 1,1980,Pages 21-23, ISSN 0031-9384, https://doi.org/10.1016/0031-9384(80)90175-4.

[3] Insulin and bone health in young adults: The mediator role of lean mass Torres-Costoso A, Pozuelo-Carrascosa DP, Álvarez-Bueno C, Ferri-Morales A, Miota Ibarra J, et al. (2017) Insulin and bone health in young adults: The mediator role of lean mass. PLOS ONE 12(3): e0173874. https://doi.org/10.1371/journal.pone.0173874

[4] Fica S, Albu A, Constantin M, Dobri GA. Insulin resistance and fertility in polycystic ovary syndrome. J Med Life. 2008 Oct-Dec;1(4):415-22. PMID: 20108521; PMCID: PMC3018970.

[5] Hill JW, Elmquist JK, Elias CF. Hypothalamic pathways linking energy balance and reproduction. Am J Physiol Endocrinol Metab. 2008 May;294(5):E827-32. doi: 10.1152/ajpendo.00670.2007. Epub 2008 Feb 19. PMID: 18285524; PMCID: PMC5724360.

[6] George B. Karkanias, Jose C. Morales, Chang-Sheng Li, Deficits in Reproductive Behavior in Diabetic Female Rats Are Due to Hypoinsulinemia Rather Than Hyperglycemia, Hormones and Behavior, Volume 32, Issue 1, 1997,Pages 19-29, ISSN 0018-506X,