July, 2006

Definition of the Problem
Diabetes mellitus (DM) refers to two related illnesses. Both affect how a person metabolizes glucose (sometimes called “blood sugar”). In Type I diabetes, the pancreas stops producing insulin, possibly because of an autoimmune process of some kind. Type I diabetics need carefully monitored insulin replacement therapy to survive. Type I diabetics make up around 10% of the diabetic population (Votey and Peters, 2005a).

In Type II diabetes, the pancreas may or may not be producing enough insulin, but the insulin receptor cells have closed down (“insulin resistance”). The liver may also be affected, producing more glucose than the body needs (Votey and Peters, 2005a).

Type II diabetes is associated with high-fat, high-calorie diets, sedentary lifestyles, overweight, and economic hardship (Black, 2002; Bo, Menato et al, 2002; Votey and Peters, 2005b).

Stress is a major contributing factor in diabetes. It raises blood glucose by stimulating the release of glucose by the liver, and can also interfere with people following their doctors’ orders and recommendations (Surwit, van Tilburg et al, 2002; Arsham and Lowe, 1997).

Scope and Cost of the Problem
Diabetes is one of the most prevalent, most expensive, and fastest growing chronic conditions in the U.S.A. and the world. About 18.2 million Americans had diagnosed diabetes in 2002 (Votey and Peters, 2005a). In 1998, their care involved 513,000 hospital admissions, averaging 5.2 days per stay (Hall and Popovic, 2000).

Direct medical expenditures for diabetes in 1997 totaled $44.1 billion – about $7.7 billion for glycemic care, and $36.4 billion for treatment of complications and excess prevalence of general medical conditions (Votey and Peters, 2005b). People visited doctor’s offices 24.7 million times in 1999-2000 for Type 2 diabetes alone (Burt and Schappert, 2004).

According to the American Diabetes Association, indirect costs of diabetes (from premature mortality and disability) in 1997 totaled $54.1 billion. Total medical expenditures incurred by people with diabetes totaled $77.7 billion or $13,243 per person, compared with $2,560 for people without diabetes (Votey and Peters, 2005). ADA research also found that in the United States, diabetes accounted for a loss of nearly 88 million disability days in 2002).

Diabetes is a chronic illness in which outcomes, quality of life, and use of medical resources depend almost entirely on patient compliance. That is, the ability to follow prescribed diet, exercise, glucose monitoring, infection prevention, and medication regimens.

But many find this program burdensome and frustrating (Polonsky, 1999). Noncompliance is the biggest cause of diabetic complications, including kidney failure, blindness, amputation, and heart disease (Arsham and Lowe, 1997). Any program that enables patients to better comply with treatment plans will be extremely valuable and cost-effective.

Medical Treatment
Medical treatment of Type I diabetes centers on insulin replacement, which is usually done by self-administered injections. Continuous insulin pumps are now available for some patients and allow for greater glycemic control and ease of treatment. Type II diabetics are usually treated with oral medications (sulfonylureas, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones) (Arsham and Lowe, 1997).

Compliance with Diabetes Treatment
The Diabetes Clinical Control Trial (NIDDKD, 2003) demonstrated that diabetics who maintain excellent glycemic control face relatively little risk of kidney failure, retinopathy, or amputation. Improvements in glucose testing technology and medications have made glucose control possible for a greater number of diabetics. Still, the physical and psychological demands of tight control are difficult for many patients.

The Role of Relaxation, Hypnosis, and Imagery
Stress reduction is a vital part of diabetes management. This is especially true in Type II diabetes, where it appears to lower blood glucose directly (Feinglos, Hastedt and Surwit, 1987; Surwit, van Tillberg et al, 2002).In Type I, the advantages of relaxation, hypnosis, biofeedback, and guided imagery appear to stem largely from improved behaviors, although there is some evidence of a direct effect (McGrady and Gerstenmaier, 1990; Ratner, Gross et al, 1990).

Researchers found that both depression and anxiety worsen glycemic control both directly, and indirectly through behavior (McGrady and Horner, 1999). Depression and anxiety can be partially relieved through relaxation and self-hypnosis (guided imagery) (Davidson, Fambach and Richardson, 1978; Stetter, Walter et al, 1994). Other researchers found that several areas of diabetes self-care behavior improved in a group of patients who listened to guided imagery tapes (Wichowski, Jubsch, 1999).

Biofeedback and relaxation significantly lowered blood glucose, A1C, muscle tension, depression, and anxiety in subjects (McGinnis, McGrady et al, 2005). Thermal biofeedback, when used alone or in combination with other mind-body techniques, can improve quality of life and the level of activity by improving blood flow, pain, neuropathy, healing ulcers (Galper, Taylor, et al, 2003).

A low-cost guided imagery-based program can improve compliance in diabetics of both types and improve glycemic control in Type II diabetics.

American Diabetes Association. Economic Consequences of Diabetes Mellitus in the U.S. in 1997. Diabetes Care. 1998 Feb;21(2):296-309.

Arsham, G, Lowe G. Diabetes: A Guide to Living Well, 3rd Edition. Chronimed Publishing. Minneapolis:1997.

Black SA. Diabetes, diversity, and disparity: what do we do with the
evidence? Am J Public Health. 2002 Apr;92(4):543-8.

Bo S, Menato G, Bardelli C, Lezo A, Signorile A, Repetti E, Massobrio M, Pagano G. Low socioeconomic status as a risk factor for gestational diabetes. Diabetes Metab. 2002 Apr; 28(2):139-40.

Burt CW, Schappert SM. Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 1999– 2000. National Center for Health Statistics. Vital Health Stat 13 (157). 2004.

Davidson, GP, Farnbach RW, Richardson BA. Self-hypnosis training in anxiety reduction. Aust Fam Physician. 1978 Jul;7(7) :905-10.
The Diabetes Control and Complications Trial Research Group [11. National Diabetes Control and Complications Trial. (1983-93). National Institute of Diabetes and Digestive and Kidney Diseases. Reported by National Diabetes Information Clearinghouse. www.niddk.nih.gov/health/diabetes/pubs/dcct1/dcct.htm
Accessed July, 2006.

Direct and Indirect Costs of Diabetes in the United States. American Diabetes Association.
Accessed July, 2006

Endocrinology Health Guide. Type I Diabetes. University of Maryland Medical Center. 2004. Scott & White Hospital and Clinic. http://www.umm.edu/endocrin/diabmel.htm
Accessed January, 2006.

Feinglos MN, Hastedt P, Surwit RS. Effects of relaxation therapy on patients with type I diabetes mellitus. Diabetes Care. 1987, Jan-Feb;10(1):72-5.

Galper DI, Taylor AG, Cox DJ. Current status of mind-body interventions for vascular complications of diabetes. Family and Community Health. 2003 Jan-Mar; 26 (1):34-40.

Hall MJ and Popovic JR. 1998 Summary: National Hospital Discharge Survey. Advance data from vital and health statistics; no 316. Hyattsville, Maryland: National Center for Health Statistics. 2000.

McGrady A, Gerstenmaier L. Effect of biofeedback assisted relaxation training on blood glucose levels in a type I insulin dependent diabetic. A case report. J Behav Ther Exp Psychiatry. 1990 Mar;21(1):69-75.

McGrady A, Horner J. Role of mood in outcome of biofeedback assisted relaxation therapy in insulin dependent diabetes mellitus. Appl Psychophysiol Biofeedback. 1999 Mar;24(1):79-88.

Polonsky W. Diabetes Burnout. American Diabetes Association.1999.

Ratner H, Gross L, Casas J, Castells S. A hypnotherapeutic approach to the improvement of compliance in adolescent diabetics. Am J Clin Hypn. 1990 Jan;32(3):154-9.

Stetter F, Walter G, Zimmermann A, Zahres S, Straube ER. Ambulatory short-term therapy of anxiety patients with autogenic training and hypnosis. Results of treatment and 3 month follow-up. Psychother Psychosom Med Psychol. 1994 Jul;44(7) :226-34.

Surwit RS, van Tilburg MA, Zucker N, McCaskill CC, Parekh P, Feinglos MN, Edwards CL, Williams P, Lane JD. Stress management improves long-term glycemic control in type 2 diabetes. Diabetes Care. 2002 Jan;25(1):30-4.

Wichowski HC, Kubsch SM. Increasing diabetic self-care through guided imagery. Complement Ther Nurs Midwifery. 1999 Dec;5(6):159-63.

Votey SR, Peters AL. Diabetes Millitus, Type 1 – A Review. 2005a. August 4. http://www.emedicine.com/emerg/topic133.htm Accessed July, 2006.

Votey SR, Peters AL. Diabetes Millitus, Type 2 – A Review. 2005b July 14. http://www.emedicine.com/emerg/topic134.htm
Accessed July, 2006.