Diabetes and Blood Glucose Levels: The Ups and Downs of Mood and Performance
I appreciate that families communicate topics that are of particular interest at a point in time. Recently, a parent asked me to discuss the relationship between mood and performance on blood glucose levels. Anecdotally, all families can note that blood glucose levels often become the focus of daily conversation and worry. Avoidance of future complications in association with low hb A1c levels is paramount, however, the daily ups and downs of blood sugar can significantly affect life's daily routine and events.
Behavior associated with high and low blood sugar is unique to every individual with diabetes; however, there are some unifying characteristics typical for everyone. The key is to understand what circumstances precipitate significant glucose fluctuations and how to either prepare, prevent, attenuate, or correct after the event or situation. Thus, it is important for the person with diabetes and family members to learn how to behave during a high or low episode and take the appropriate corrective action.
A word about physiology: our blood glucose levels are primarily affected by insulin and the counter-regulatory hormones (glucagon, growth hormone and cortisol) as well as stress hormones (epinephrine and norepinephrine). Insulin enables blood glucose to enter the cells from the blood. As a result, serum glucose levels decrease. The counter-regulatory and stress hormones act to increase glucose levels by metabolizing stored liver glycogen into glucose with release into the circulatory system. By understanding the relationships between these hormones, we can interpret why blood glucose may rise:
1) In the morning secondary to the dawn phenomenon (release of cortisol and growth hormone at night).
2) After a stressful day at work or school (release of epinephrine/norepinephrine and cortisol).
3) After an altercation with significant other, friend, teacher, supervisor, etc. (cortisol/epinephrine/norepinephrine).
4) After a severe hypoglycemic episode (results in the release of glucagon that stimulates breakdown of glycogen in the liver). The Somogyi phenomenon (rebound hyperglycemia) is an example.
5) Before a sporting event (excitement in anticipation of the big game with the release of epinephrine and norepinephrine).
6) In anxiety provoking situations such as SATs, MCATs, school exams, airplane flights (cortisol, epinephrine/norepinephrine).
7) In situations wherein medications such as prednisone (a steroid) is prescribed.
Specific strategies are employed to diagnose and treat these situations. Indeed, much of our diabetes visits discuss patterns in which hyperglycemia and hypoglycemia occur. School and work performance may be affected by marked fluctuations of blood glucose, as well as chronic hyper/hypoglycemia. Many children that present with new onset diabetes often have had difficulty concentrating in school with a recent drop in typical school performance due to undiscovered hyperglycemia. We often discover, for example, that students having difficulty in math class at 10 am may not have learning problems; but rather hypoglycemia resulting from the breakfast insulin dose. By changing the insulin/carbohydrate ratio, or the amount of bolus insulin we may be able to rectify the problem. The importance of self blood glucose monitoring, therefore, cannot be overstated.
Post-exercise induced hypoglycemia is another factor that may affect performance and mood. It is essential to monitor blood sugars for up to 24 hours after significant exercise. Levels of insulin are very important before, during, and after exercise. Indeed, it is important to note that if one starts to exercise with hyperglycemia and ketones present, blood sugars will continue to increase and not decrease, as one would expect. After exercise, cells suck up the glucose in the blood leaving the person with diabetes susceptible to hypoglycemia; hence we employ strategies such as lower basal rates or less basal insulin for the appropriate time period.
Many people with diabetes feel "low" with a rapid drop in glucose post rapid acting insulin administration even if their blood sugar is >70 mg/dl. It is important, therefore, to test blood sugar and not over treat with rapid acting carbohydrate. Conversely, people walking around with chronically high blood sugars are often "cranky" and feel "low" when their blood sugars are actually normalized because they have become accustomed to higher glucose levels. Persistent fluctuations of blood sugars often provoke moodiness and irritability and should be minimized as much as possible. Intensive insulin therapy with multiple daily injections or insulin pump therapy may help to attenuate fluctuating blood sugars. To maximize performance and enhance mood, work with your diabetes team to negotiate strategies to minimize episodes of hyper/hypoglycemia and fluctuating blood sugars.
If you're in the DC area, be sure to purchase a ticket to the April 25 game between the Washington Nationals and Los Angeles Dodgers and support children with diabetes!