According to The Holmes-Rache Life Stress Inventory (2008) these are the top ten stresses in life:
10) Death of a spouse (and, in my opinion: death of a child)
8) Marital separation or separation from a relational partner
7) Jail term
6) Death of a close family member
5) Personal injury or illness
3) Fired from work
2) Marital reconciliation
In today's climate, it is clear that all 10 stressors have plagued the world's population. Our current financial troubles have led directly to at least six of these top 10 stressors (death of a spouse-suicide, divorce, marital separations, jail term, fired from work, and in some cases, retirement). Coping with profound stress (whether good or bad) has a major impact on bodily function and hormone interaction. Our physiology is based on the "fight or flight" response that enabled our survival as a species. As such, when confronted with a modern stressful situation, "action" hormones are released to enable as to fight or run away (figuratively, of course). These hormones include primarily cortisol, glucagon, epinephrine (adrenalin), and norepinephrine (noradrenalin). ALL of these hormones function to allow some form of action to occur, and thus, increase the concentration of blood glucose for energy. These same hormones are released in children, teens, and adults with diabetes and are responsible for hyperglycemia that may occur in times of stress.
Over the last few months, I have had the sad experience of seeing families and patients who have endured many of these profound life stressors. The majority of families are just trying to cope with altered life circumstances, let alone manage diabetes "highs and lows." Therefore, I thought it wise to discuss the importance of damage control in association with reflective listening and emphasize the importance of mental stability, of which sometimes initially, at least, might be at the expense of meticulous diabetes self-care skills.
In situations involving the loss of a spouse (parent) or a child (sibling), our first goal is overall support. Usually in these circumstances, our diabetes team is not always notified and we may be seeing the family several weeks or month after the tragedy. Generally, diabetes control is not a major priority in these situations resulting in somewhat higher hemoglobin A1c and more variability of blood sugars. Families often feel guilty about neglecting their usual roles as supportive caregivers and the child or teen may be checking blood sugars less frequently or forgetting insulin boluses etc. This is NOT the time to be insistent on meticulous diabetes related behavior. This is the time to promote "damage control." Naturally, given an ideal situation, I would suggest more vigilance in diabetes care to decrease the significant highs and lows associated with profoundly stressful situations. However, this is clearly not always possible in bereaved and highly stressed families.
These situations are particularly difficult for the diabetes team as in most cases there is a long history of interaction between families and their children. In many circumstances, our team is grieving as well and share the sadness expressed by family members. Our goal in these trying situations is to encourage the family "to keep afloat" by remembering to give the insulin before meals and to try to check blood sugars as often as possible. Perfect glycemic control would be ideal, but very unlikely in these stressful situations simply due to the biological response to stress and grief. An increase in those counter-regulatory hormones elevates blood glucose. We try to be as supportive as possible and ask the families to call our office frequently not only to analyze blood sugars and adjust insulin but to listen reflectively. If possible, we offer the services of our psychosocial team to counsel the family members individually. In summary, we make ourselves available in any supportive means possible. We become a support system to help the family go through this life event and do not emphasize perfection in management, but rather maintenance to emerge "on the other side." We reinforce that the high and low blood sugars are to be expected due to hormones, lack of appetite, sadness, and disruption in daily routine and provide suggestions to minimize the variability of those blood sugars.
In summary, our diabetes team recommends the following to all families undergoing profound and significant life-altering events:
- Reach out for support--people are out there willing to help. Try not to isolate yourself or your family.
- Contact your diabetes team as soon as possible, so that we are aware of the situation and provide the support that may be needed.
- Try to allow for lapses in usual conscientious situations and be easy on yourself.
- Delegate some of your child's diabetes-related responsibilities to another family member or friend, etc.
- Expect variability of blood sugars and don't feel guilty.
- Try to remember to check blood sugars as much as possible (not to worry if you check four times/day instead of your usual eight times/day.) Checking blood sugars is essential to avoid the possibility of DKA or severe hypoglycemia.
- Consider counseling to develop healthy coping strategies.
- Remember (even if you need someone to remind you) to receive or give insulin to avoid further problems.
- Remember to eat and drink (especially) to avoid hypoglycemia as much as possible.
- Be kind to yourself and family members. Avoid the need to answer all expectations.
Read more on Diabetes and Stress, and tips on how you can tackle it.
Published On: April 27, 2009