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Understanding diabetes burnout: strategies for coping and overcoming.

Monitoring blood sugar levels, adhering to dietary restrictions, and managing medications can be overwhelming and can leave a person with diabetes exhausted, frustrated, and even depressed. 

Some experts call this phenomenon " diabetes burnout ," which we will discuss in this article, along with its symptoms, causes, and management strategies. We will also explore the difference between burnout, distress, and depression, showing how each manifests and affects people with diabetes. By understanding the symptoms and triggers of burnout, patients, their support group, and their care team can better address and cope with the challenges of managing diabetes effectively.

• Diabetes burnout affects well-being alongside distress and depression.
• It is caused by exhaustion from managing diabetes, leading to neglect of self-care.
• Triggers include stressors, treatment challenges, and fear of complications.
• Symptoms include fatigue, neglecting tasks, emotional distress, and avoidance.
• It differs from diabetes distress and depression, with burnout focusing on exhaustion related to management, while distress encompasses broader challenges, and depression involves feelings of sadness and hopelessness.
• Coping strategies include self-care, realistic goals, seeking support, and lifestyle adjustments.
• Lifestyle changes like mindfulness, sleep, diet, exercise, and boundaries can help.

What is Diabetic Burnout?

Diabetes burnout is the emotional and physical exhaustion resulting from the challenges of living with and managing diabetes, leading to feelings of being overwhelmed and disillusioned.

"People who experience diabetes burnout often feel like giving up. As a result, they may avoid diabetes self-management tasks," says  Julia Blanchette, PhD, RN, BC-ADM, CDES , a lead nurse scientist and diabetes care and education specialist at University Hospitals Cleveland Medical Center and an Assistant Professor of Medicine at Case Western Reserve University.

Having diabetes means having to manage it carefully and take a lot of medicine. So, it is common for people with diabetes to feel emotionally and mentally tired. Studies show that people may go through diabetes burnout in different ways, but it usually means feeling overwhelmed and unable to handle daily engagement with self-care. Consequently, those going through diabetes burnout may distance themselves from their diabetes care.

What Are the Causes and Triggers of Diabetes Burnout?

Living with diabetes is a chronic condition that requires consistent management and attention. Managing diabetes is a relentless journey, and several factors can cause a patient to burn out. Understanding these causes and triggers is essential for effectively addressing and managing burnout. A 2021 study gives some factors that can trigger diabetes burnout:

Daily Management Tasks

Balancing blood sugar checks, medication adherence, and dietary restrictions can feel overwhelming. Managing diabetes involves several daily tasks like checking blood sugar levels at intervals, using your medications as prescribed by your doctors, following a specific diet, and regularly engaging in physical activity. Sticking to a somewhat rigid schedule can become overwhelming and tiresome, causing burnout.

Emotional and Psychological Stressors

Coping with stress, anxiety, and depression associated with diabetes management can take a toll on anyone. Coping with the stress of managing diabetes, worrying about potential complications, and dealing with anxiety or depressive symptoms can trigger burnout. Emotional challenges can make staying motivated and engaged in daily management tasks difficult.

Social and Lifestyle Challenges

Lack of support, unrealistic treatment goals, and difficulties with exercise can contribute to burnout. Unrealistic treatment goals or expectations, such as striving for perfect blood glucose levels, can be pretty frustrating. Consistently feeling unable to meet target A1C or other treatment objectives can lead to a sense of failure or inadequacy. Limited support from family, friends, or the healthcare team can make it harder to cope with the demands of diabetes management. Management tasks can impact productivity at work and can be not very pleasant. Incorporating exercise into daily routines or maintaining healthy living can also be challenging.

Treatment Challenges

Dealing with complications, finding the proper medication, sticking to a treatment plan, and navigating treatment costs can add to the burden. Finding an effective insurance plan with good coverage and access to healthcare resources may also not be straightforward. The financial burden of treatment costs can be exhausting. Experiencing and switching between hypoglycemia and hyperglycemia can cause stress and frustration that leads to being burned out.

Other Factors

Fear of hypoglycemia, experiencing stigma or discrimination because you have diabetes, and constant need for self-care can also trigger diabetes burnout.

Diabetes burnout can happen from a combination of factors and may vary from person to person.

What Are the Signs and Symptoms of Diabetes Burnout? 

The signs and symptoms of diabetes burnout may vary in different individuals, but common signs include:

• Feeling tired all the time: Managing diabetes can be exhausting.
• Neglecting diabetes self-care tasks: You might forget to check your blood sugar, take your medicine, follow a healthy diet, and engage in regular physical activity like you should.
• Emotional distress: You might feel more easily annoyed, irritable, frustrated, or upset about dealing with diabetes stuff. You might experience more strong negative feelings.
• Feeling overwhelmed or defeated by diabetes management: You might feel overwhelmed by the constant vigilance required to manage diabetes effectively, leading to a sense of hopelessness or defeat.
• Avoiding diabetes-related tasks or appointments: You might avoid scheduling or going for regular check-ups with your doctor or attending diabetes education classes.
• Changes in blood sugar levels : Your blood glucose levels might increase or lower than usual because of stress and burnout.
• Feeling more stressed, anxious, or sad: You might feel more stressed out, worried, or sad because of everything you are dealing with.
• Loss of interest in activities previously enjoyed: People who experience diabetes burnout feel too overwhelmed or exhausted to enjoy activities that were once fun and fulfilling.
• Difficulty maintaining motivation or adherence to treatment plans: It might be more challenging to stay motivated and keep up with your diabetes care plan because you feel overwhelmed.

It is essential to talk to your diabetes care team if you feel any of these symptoms. They can provide support and tips for handling better.

How Diabetes Burnout Impacts Your Well-being

Diabetes burnout can affect how you feel and function in everyday life. Here's how it can impact you:

• Physical Health:  Forgetting to keep track of your blood sugar levels, skipping medications, or not eating well can make your blood glucose levels go haywire. This can lead to more health problems down the line.
• Emotional Well-being: Managing diabetes can be stressful and overwhelming, and burnout can make these feelings even more vital. You might feel frustrated, hopeless, or tired of dealing with everything.
• Mental Health: Diabetes burnout can also make it hard to think clearly. You might have trouble concentrating, remembering things, or making decisions. It can take a toll on the mental health.
• Quality of Life: Burnout can suck the joy out of life. You might not feel like doing things you love anymore and find it harder to connect with others.

Recognizing burnout and reaching out for support can help you get back on track. Taking small steps to care for yourself and finding healthy ways to cope can make a big difference in how you feel and manage your diabetes.

Diabetes Distress Vs. Diabetes Burnout

Diabetes distress is when people living with diabetes feel a great deal of emotional stress, anxiety, or frustration because of managing diabetes. It also includes feeling overwhelmed by diabetes self-management tasks and worrying about complications. It can fluctuate over time and may peak during challenging periods and heightened general stress. If it is untreated, mild diabetes distress can become severe diabetes distress and depression.

Severe diabetes distress is linked to adverse medical and psychological effects, such as:

• Not managing diabetes well (like not being active enough, eating less healthily, not taking medication as advised, and checking blood sugar less often).
• Increased levels of HbA1c (a measure of blood sugar over time).
• Having more severe low blood sugar episodes.
• Decreased quality of life.

This 2020 study shows how some people living with diabetes distress and diabetes burnout are separate but are closely linked due to distress and depressive symptoms. Some people see burnout as similar to distress and depression, while others feel distress leads to burnout and depressive symptoms.

Feelings Associated with Diabetes Distress

People living with diabetes distress may feel a range of emotions that include:

• Powerlessness:  Feeling overwhelmed and powerless because of constant diabetes management needs .
• Anger: People with diabetes can experience diabetes distress due to the impact of diabetes on their daily lives.
• Frustration: Feeling frustrated with constant monitoring and unpredictability of blood glucose levels.
• Anxiety: Persistent fear or worry about treatment plans and complications can contribute to feelings of anxiety.
• Guilt or Shame: Feeling guilty or ashamed about perceived failures in diabetes management, like missing medication doses, blood sugar checks, or deviating from the diet, can weigh heavily on a patient.
• Loss of Control: Feeling like diabetes controls one's life and choices can lead to a sense of helplessness or loss of control, adding to distress.
• Isolation or Loneliness: People with diabetes may struggle to find understanding or support from others who do not share their experiences. Bearing this burden can sometimes lead to feelings of isolation and loneliness.

Similarities between Distress and Burnout

Many feelings associated with diabetes distress are similar to the feelings you experience with diabetes burnout. They both involve emotional responses to challenges faced when managing diabetes. These feelings are:

• Powerlessness in diabetes management
• Anger towards diabetes and required management tasks
• Frustration
• Being overwhelmed

Diabetes distress can result in diabetes burnout if it occurs over an extended period.

Differences between Distress and Burnout

There are similar feelings between diabetes distress and burnout, but there are also significant differences:

• Scope:  Diabetes distress may cover a broader range of emotional and psychological challenges associated with living with diabetes, while diabetes burnout refers explicitly to feelings of exhaustion and depletion related to diabetes management.
• Duration: Diabetes burnout can happen over a more extended period and may require more intensive interventions to address; however, diabetes distress may fluctuate in intensity over time.
• Intensity: Diabetes burnout tends to be more severe, exhausting, and impairing than diabetes distress; it often results in feelings of physical exhaustion and emotional stress that interfere with daily functioning.

Depression Vs. Diabetes Burnout

Depression is a mental health disorder that comes with feelings of sadness, hopelessness, and losing interest in things they used to enjoy. It can make someone feel tired, have trouble sleeping, and struggle concentrating. It is like a dark cloud hanging over them, making everything seem harder. Depression can significantly impact daily functioning and quality of life, and it often requires treatment such as therapy, medication, or a combination of both.

Research shows that the rate of depression is more than three times higher in people with type 1 diabetes and nearly twice as high in people with type 2 diabetes. It also explains that women with diabetes and women without diabetes experience a higher prevalence of depression than men. Reviewed studies show a modest relationship between diabetes and depressive symptoms, but the exact elements of this relationship remain unclear.

Depressive symptoms indicate that it is a general emotional state. While diabetes burnout and diabetes distress primarily manifest in the context of living with diabetes, they may not manifest in other areas of the person's life.

Another difference is how they affect blood sugar levels. This research shows how high levels of diabetes distress can make it hard to manage diabetes, leading to higher A1C levels. Some studies suggest the same for diabetes burnout. But for depression, the link to A1C levels isn't clear. Some studies don't find a connection. This means depression might affect people with diabetes differently than diabetes burnout or diabetes distress.

Depression can mess up daily life in many ways. It can make sleeping, eating right, or even getting out of bed hard. People may feel tired, lose interest in things they used to enjoy, and have trouble focusing. They might also want to be alone more and forget to care for themselves. Some might even turn to drinking or drugs to feel better. Getting help is essential to start feeling better and getting back on track.

Strategies for Coping and Overcoming Diabetes Burnout 

Living with diabetes can sometimes feel overwhelming, and it's expected to experience burnout from time to time. When you're dealing with diabetes burnout, it can be hard to stay motivated and manage your condition effectively. The Centers for Disease Control and Prevention (CDC) suggests that people who experience diabetes burnout should;

• Involve the health care team.
• Lean on the diabetes community.
• Remember that perfection is not possible.

However, other strategies can help you cope and overcome burnout. Here are some simple tips to help you manage diabetes burnout and feel more in control of your health:

• Acknowledge your feelings: It's okay to feel overwhelmed or frustrated with managing diabetes. Recognize and accept your feelings.
• Set achievable goals: Don't aim for perfection. Set small, realistic goals for managing your diabetes and celebrate your successes.
• Take breaks and connect with others: Permit yourself to take breaks from diabetes tasks when needed. Do other things aside from those tasks; do not skip your tasks. Make sure you rest and recharge to avoid feeling burnt out. Do things you enjoy and spend time with loved ones to relax. Have a whole life that does not revolve around your condition.
• Get support: Reach out to friends, family members, or support groups who understand what you're going through. Sharing your feelings with others who can understand can provide validation and encouragement. Several support groups offer supportive environments where you meet people with similar experiences. You can also consider therapy, which can provide strategies for managing stress and improving coping skills.
• Talk to your healthcare team: Be honest with your doctor about your feelings. They can provide guidance and make adjustments to your treatment plan if necessary.
• Focus on what you can control: Accept that managing diabetes has ups and downs. Concentrate on what you can control and let go of what you can't.
• Learn more: Educate yourself about diabetes management and self-care. The more you know, the better equipped you'll be to manage your diabetes effectively.

Adapting Your Lifestyle as a Strategy for Dealing with Burnout

One effective strategy for dealing with burnout is to adapt your lifestyle. This means changing your daily routines and habits to manage stress better and prioritize self-care. Healthy living can help reduce the effects of burnout. Here are some ways you can adapt your lifestyle to cope with burnout:

• Prioritise Self-care: Make time for activities that help you relax and recharge, such as exercise, meditation, or hobbies you enjoy.
• Establish Boundaries: Learn to say no to commitments or responsibilities that add unnecessary stress to your life. Setting boundaries can help protect your time and energy.
• Practice Mindfulness: Stay present in the moment and focus on one task at a time. Mindfulness techniques, such as deep breathing or guided imagery, can help reduce stress and improve mental clarity.
• Get Enough Sleep: Aim for 7-9 hours of quality sleep each night. Prioritize sleep hygiene practices, such as creating a relaxing bedtime routine and avoiding screens before bed, to improve sleep quality.
• Eat Healthily: Fuel your body with nutritious foods that support overall well-being and don't increase your blood sugar. Eating a balanced diet can help stabilize energy levels and improve mood.
• Stay Active: Incorporate regular physical activity, such as walking, cycling, or yoga. Exercise releases endorphins, which can boost mood and reduce stress.

Remember, you're not alone in dealing with diabetes burnout. By implementing these simple strategies and seeking support when needed, you can overcome burnout and feel more in control of your diabetes management. Diabetes can be very unpredictable, making managing it tricky. Break your treatment goals into small steps.

Diabetes burnout is a significant challenge for people with diabetes; it impacts their emotional well-being and overall quality of life. By recognizing the signs, understanding the triggers, and implementing effective coping strategies, individuals can better navigate the complexities of diabetes management. By prioritizing self-care, seeking support, and making lifestyle adjustments, individuals can overcome burnout and regain health control. With continued awareness and proactive management, patients can thrive in diabetes management and lead fulfilling lives.

At Diabetic Me, we are committed to delivering information that is precise, accurate, and pertinent. Our articles are supported by verified data from research papers, prestigious organizations, academic institutions, and medical associations to guarantee the integrity and relevance of the information we provide. You can learn more about our process and team on the about us page .

• National Library of Medicine Unraveling the concepts of distress, burnout, and depression in type 1 diabetes: A scoping review
• University Hospitals Julia Blanchette, RN, PhD
• National Library of Medicine Burnout Related to Diabetes Mellitus: A Critical Analysis
• Springer Link The Value of Measuring Diabetes Burnout
• Diabetes UK Diabetes Distress
• Diabetes Research and Clinical Practice New insights into diabetes burnout and its distinction from diabetes distress and depressive symptoms: A qualitative study
• Science Direct Relation between diabetes related distress and glycemic control: The mediating effect of adherence to treatment
• Science Direct Epidemiology of depression and diabetes: A systematic review
• Science Direct Development and validation of a scale to measure diabetes burnout
• National Library of Medicine The Association of Hemoglobin A1c Levels and Depression Among Adults With Diabetes in the United States
• CDC Dealing With Diabetes Burnout

Not all symptoms should be immediately tagged as ‘burnout.’ It’s essential to distinguish between actual burnout and just having a rough day. Aren’t we risking overdiagnosing here?

There’s a clear clinical distinction between daily stress and diabetes burnout. Burnout involves a prolonged period of feeling overwhelmed and disconnected from diabetes management.

do u guys think stress from school can kick off this burnout thing? asking cuz my bro got diabetes and he’s always freaking out bout school.

finally someone talks about the REAL struggle with diabetes. its not all numbers and food, its the burnout! we need more support and understanding, THANKS Ely Fornoville for putting it out there!

Yeah agree, support is key. But also think lifestyle changes can make a big difference in managing diabetes.

Absolutely. It’s crucial to maintain a balance and address both physical and mental health aspects.

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About the Author

Ely fornoville.

Living with type 1 diabetes since 1996 has shaped who I am and fueled my passion for helping others navigate their own diabetes journey. As the founder of Diabetic Me, I share insights, tips, and stories from fellow diabetics around the world. With the Medtronic Guardian 4 CGM and MiniMed 780G insulin pump by my side, I strive to empower others to manage their diabetes and live life to the fullest.

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Diabetes burnout among emerging adults with type 1 diabetes: a mixed methods investigation

• Published: 10 February 2021
• Volume 44 , pages 368–378, ( 2021 )

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Feeling overwhelmed, exhausted, and frustrated by the daily demands of diabetes management has been referred to as diabetes burnout. The goal of the study was to develop a measure of diabetes burnout and to link this measure to psychological health and diabetes outcomes. Emerging adults with type 1 diabetes ( n  = 88, average age 27) completed an online questionnaire and an HbA1c assessment; a subset was interviewed by phone to obtain a more in-depth understanding of burnout. Exploratory factor analysis revealed three burnout domains: exhaustion, detachment, and powerlessness. Burnout was related to higher psychological distress, higher diabetes distress, and poorer diabetes outcomes. Burnout independently predicted higher HbA1c, independent of diabetes distress. Qualitative interviews revealed that participants defined burnout in terms of exhaustion and powerlessness and resolved burnout by acceptance and utilization of social resources. Prevention and intervention efforts might target resilience as a way to mitigate burnout.

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This research was supported by National Institutes of Health R01 DK060586.

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The author is grateful to Michele Joseph for interviewing the participants and to Abigail Vaughn who facilitated data collection and analysis, as well as the participants who persisted with this study. Contact information: Vicki S. Helgeson, Psychology Department, Carnegie Mellon University, Pittsburgh, PA 15,213, [email protected].

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Helgeson, V.S. Diabetes burnout among emerging adults with type 1 diabetes: a mixed methods investigation. J Behav Med 44 , 368–378 (2021). https://doi.org/10.1007/s10865-020-00198-3

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DOI : https://doi.org/10.1007/s10865-020-00198-3

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SAMEREH ABDOLI , AMIT C. VORA , DANIELLE M. HESSLER , HEATHER L. STUCKEY; I Wanted Diabetes Out—Lived Experiences of Diabetes Burnout from Bloggers with Type 1 Diabetes. Diabetes 1 July 2018; 67 (Supplement_1): 65–LB. https://doi.org/10.2337/db18-65-LB

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Objective: To define and understand diabetes burnout through thematic analysis of narrative posts, written by adults with type 1 diabetes (T1D), published in publicly available blogs.

Research Design and Methods: A qualitative thematic analysis of 35 posts published in 21 blogs from the U.S., UK, and Ireland, written by adults with T1D, provided the basis for definition(s) of diabetes burnout. Data management (Nvivo 11 Pro) and analysis included three phases: immersion, reduction, and interpretation (kappa=.91).

Results: Findings included five main themes that described diabetes burnout: (1)Burnout is a “detachment” from diabetes care; (2) the “demanding life” of diabetes leads to burnout; (3) struggling with “perfect” numbers adds to burnout; (4) “life events” are catalysts to burnout; (5) and overcoming burnout is like “climbing out of a difficult hole.”

Conclusions: Analysis of blogs provided unique insights into the concept of diabetes burnout. Five themes were identified that ranged from detachment from diabetes care to difficulties in overcoming diabetes. These data provide a next step into understanding diabetes burnout and factors that may co-occur. Further research needed to advance science of diabetes burnout to improve quality of care and quality of life of individuals with diabetes.

S. Abdoli: None. A.C. Vora: Speaker's Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Novo Nordisk Inc., Sanofi-Aventis, Janssen Pharmaceuticals, Inc. D.M. Hessler: Consultant; Self; Eli Lilly and Company. H.L. Stuckey: Consultant; Spouse/Partner; Calibra Medical, Eli Lilly and Company. Research Support; Spouse/Partner; Novo Nordisk Inc.. Research Support; Self; Eli Lilly and Company, Novo Nordisk Inc..

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CE: Original Research: Experiences of Diabetes Burnout: A Qualitative Study Among People with Type 1 Diabetes

Abdoli, Samereh PhD, RN; Hessler, Danielle PhD; Vora, Amit MD, FACE; Smither, Betsy MPH, CHES; Stuckey, Heather DEd

Samereh Abdoli is an assistant professor in the College of Nursing, University of Tennessee, Knoxville, where Amit Vora is a clinical assistant professor in the Graduate School of Medicine. Danielle Hessler is an associate professor in the Department of Family and Community Medicine, University of California, San Francisco. Betsy Smither is a project manager at Oak Ridge Associated Universities, Oak Ridge, TN. Heather Stuckey is an associate professor in the Departments of Medicine, Public Health Science, and Humanities at Pennsylvania State University, Harrisburg. This study was supported in part by an unrestricted grant from the Beryl Institute. Contact author: Samereh Abdoli, [email protected] . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

Background: 

People with type 1 diabetes are at increased risk for diabetes burnout, resulting in suboptimal diabetes care and quality of life. While the existence of diabetes burnout is widely acknowledged, there is no evidence-based definition, means of measurement, or interventions to address it.

Objective: 

This study was aimed at increasing our understanding of the lived experiences of diabetes burnout among adults with type 1 diabetes.

Methods: 

A qualitative descriptive study was conducted with a sample of 18 adults with type 1 diabetes who reported a current or previous experience of diabetes burnout. Data were collected using in-depth interviews and analyzed using qualitative content analysis.

Results: 

Four main themes were identified: mental, emotional, and physical exhaustion from having diabetes; detachment from illness identity, diabetes self-care, and support systems; contributing factors to diabetes burnout; and strategies for preventing or overcoming diabetes burnout.

Conclusion: 

Although exhaustion is an entry point for diabetes burnout, the findings suggest that detachment from illness identity, diabetes self-care, and support systems form a core component. Detachment may explain poor outcomes in individuals experiencing diabetes burnout.

The authors conducted in-depth interviews with adults who have type 1 diabetes and current or previous experiences of diabetes burnout to learn more about their lived experiences, as well as the nature of burnout and its contributing factors.

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Diabetes burnout: a common but neglected impact of diabetes

Research conducted by t1international finds that people living with diabetes are experiencing diabetes burnout at a very high rate, with a significant impact on their health and wellbeing., share this:.

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Credit: T1International and Erin Lubin

In June, T1International shared a blog post outlining the phenomenon of diabetes burnout , which is the loss of strength or motivation, usually as a result of prolonged stress in regards to diabetes management and care. At the end of this post, our team included a questionnaire for people with diabetes to address burnout effects and what factors contribute to this feeling. While circumstances and realities vary for all individuals, some notable patterns emerged that everyone in our community should be aware of and concerned about.

While we were enthused by the number of participants and support, the results of the survey painted a picture of a diabetes community faced with prolific burnout that many are confronting alone. In this article, we take a look at what the data means for people facing a condition that is ever present and in the forefront of mind of a person living with diabetes.

Of the 107 people who took the questionnaire, over 74% have lived with diabetes for more than 10 years. This means that the majority of participants have been managing their condition for a significant portion of their lives.

Overall, people with diabetes are experiencing burnout at a very high rate, with over half (55%) of respondents reporting they experience burnout much or all of the time. One in seven (14%) of these consider diabetes burnout as an ongoing condition that is always present in their life.

I feel overwhelmed while taking care of diabetes tasks and remember (even though I’ve had this half of my life) that I’ll have to do this forever. I push through. But it can be exhausting. I wish we got a break sometimes!

This feeling of burnout has a clear and definite impact on the lives of people with diabetes. Over half of respondents (57%) reported a strong or overwhelming impact that takes the form of lack of sleep, feelings of depression and anxiety and neglect of blood glucose management. When sharing their experience, people noted feelings such as anger and lethargy in the face of constant stress.

Those who took the questionnaire were given free space to express their thoughts or feelings on the topic, and noted that their stress presents in different ways. Many experience stress related to their supplies, adequacy of access and insurance coverage. Others experienced poor eating habits and lapses in care as a result of their burnout. A common issue reported is the continuous presence of a condition that utterly drains their energy.

Despite this, a staggering number of people with diabetes (62% of participants) are not seeking any support from friends, family or mental health professionals. Furthermore, less than a quarter (24%) claimed they feel comfortable talking with their own doctor about this burnout. Many sacrifice seeking help from professionals at the cost of mental health. We would venture to assume that those who feel unsupported by their community have a higher chance of poor management compared to those who have a strong support system.

It’s a daily routine. When the constant lows and highs hit due to something I ate or did or didn’t even do in my daily life, it can get hard to handle. I always get past it and start a new day, but it’s not easy to deal with the mental strain of feeling a sense of failure and how that may affect me later down the line with diabetes complications.

In reviewing the information and statements provided freely by survey participants, diabetes burnout leads people with diabetes to feelings of anxiety, depression and frustration. For many, the persistent management and attention that the condition requires leads to feelings and stress that manifest in other areas of their lives.

Burnout appears very common among people with diabetes. Most of the time it remains unaddressed or untreated by healthcare professionals. In seeking solutions, a sizable number of participants (44%), reported that online communities such as T1International are helpful in terms of support for diabetes care and burnout.

It is notable and concerning that online spaces are filling gaps that healthcare systems across the world should be addressing. While inadequate access to insulin and supplies is a major cause of diabetes burnout, the survey shows that regardless of access, burnout is experienced by almost all respondents (97.1%) at some point in their life.

It becomes harder to make good decisions regarding my diabetes management because it feels overwhelming. I often also eat more, meaning more dosing/adjustment is needed. I do take care of myself, but it’s not the best care and my fatigue towards this situation bleeds over into other aspects of my daily life, especially as it pertains to mood. It is just harder for me to do things, broadly speaking.

In the future, healthcare professionals and institutions should consider the impacts chronic conditions have on other elements of the lives of people with diabetes and their ability to manage these conditions in the long term. People living with diabetes understand all too well that healthcare professionals, who do not have to contend with the condition on a daily basis, can never fully grasp how challenging it is to live with it. It is therefore important that governments and institutions around the world prioritize and dedicate more resources for mental health support for people with diabetes.

Elizabeth Pfiester and Katherine Souris contributed to this article.

Elizabeth is founder and executive director of T1International. She has lived with type 1 diabetes for over 30 years.

Katherine is a consultant with T1International. She has lived with type 1 diabetes for 17 years.

Konstantina Taki is a medical doctor and a Digital Advocate volunteer with T1International, a non-profit advocacy organisation representing people with diabetes around the world. She has lived with type 1 diabetes for 14 years. Ian Devaney is the Communications Coordinator at T1International. He has lived with type 1 diabetes for 3 years.

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Fatigue in Patients with Diabetes: A Review

Cynthia fritschi.

1 Department of Biobehavioral Health Science, University of Illinois at Chicago, College of Nursing

Laurie Quinn

Fatigue is a common and distressing complaint among people with diabetes, and likely to hinder the ability to perform daily diabetes self-management tasks. A review of the literature about diabetes-related fatigue was conducted with an eye toward creating a framework for beginning to conduct more focused studies on this subject.

A literature search containing the terms diabetes, fatigue, tiredness, and symptoms was conducted to search for literature that addressed diabetes-related fatigue.

Diabetes presents many potential pathways for fatigue, but focused studies on this symptom are rare. Furthermore, research on diabetes-related fatigue is limited by fatigue's non-specific symptoms and because fatigue researchers have yet to agree on standardized definition, measurement or diagnostic criteria. Additionally, few diabetes randomized clinical trials included measurement of patient-reported outcomes, such as symptoms or health-related quality of life in their study designs, though one that did provided some the meaningful finding that symptom-focused education improved self-management practices, Hb A1c levels, quality of life and symptom distress.

There is a need to standardized definition, measurement and diagnostic criteria of fatigue in diabetes. We present a model that can guide focused studies on fatigue in diabetes. The model capitalizes on the multidimensional phenomena (physiological, psychological, and lifestyle) associated with fatigue in diabetes.

Introduction

Diabetes mellitus, a major public health problem, affects approximately 6% of the world's adult population, and is increasing in epidemic proportions. 1 , 2 Among people with diabetes, fatigue is a pervasive and distressing complaint. Although fatigue also occurs in other medical disorders, the importance of fatigue may be greater in individuals with diabetes. Clinicians who work with patients affected by diabetes have noted anecdotally the considerable toll that fatigue takes on their patients, yet there is little empirical research describing the severity of the problem. Fatigue in diabetes may be associated with physiological phenomena, such as hypo- or hyperglycemia or wide swings between the two. Fatigue may also be related to psychological factors, such as depression or emotional distress related to the diagnosis or to the intensity of diabetes self-management regimens. Fatigue may also be related to such lifestyle issues as lack of physical activity or being overweight--especially common in people with type 2 diabetes. Research is needed to clarify these relationships in order to help people with diabetes manage this symptom.

Herein, we review the existing literature about diabetes-related fatigue with an eye toward creating a framework for beginning to conduct more focused studies on this subject.

Definitions of Fatigue

Fatigue is a word commonly used in everyday conversations, with subjective meanings as varied as the individuals using it. Terms including fatigue, sleepiness, tiredness, lacking energy, and exhaustion are used interchangeably. Within the scientific literature, definitions of fatigue vary greatly, and defining fatigue becomes more challenging because there is poor differentiation among causes, indicators, and effects 1 , 2 . Fatigue has largely been defined as either a subjective symptom or an objective performance decrement 3 , but has also been identified as a syndrome unto itself (chronic fatigue syndrome). Fatigue is generally acknowledged to be complex and/or multifaceted 4 - 6 , encompassing physiological, psychological, and situational components, such as life or work events 4 - 13 .

While fatigue is considered a normal occurrence in daily life, it is also a symptom associated with a variety of physiological and psychological conditions. Fatigue normally occurs after mental or physical exertion, inadequate sleep, or other temporary phenomena. Sometimes called acute or healthy, such fatigue is usually temporary and alleviated with rest. Acute fatigue serves as a protective mechanism by signaling the body's need for rest. Chronic, or pathologic fatigue, however, occurs after modest effort and continues despite rest. 10 , 16 , 17 Terms such as “unrefreshed by sleep” or “unresponsive to rest” have been used by some authors to differentiate chronic fatigue from acute. 7 - 9 , 13 , 18 This type of 8 , 14 , 15 fatigue is most notably associated with diseases such as cancer, chronic obstructive pulmonary disease, rheumatoid arthritis, depression, and fibromyalgia, but it may also play a significant role in diabetes.

A common view is that fatigue results from one or a combination of peripheral physiologic processes--alone or in combination with the brain and/or its neurological systems. Fatigue has been distinguished as “peripheral” and “central” depending on which processes and systems are involved. Peripheral fatigue has been described as a purely physiologic phenomenon, involving an end organ such as skeletal or cardiac muscle and has been defined as “the decline in muscle tension (force) capacity with repeated stimulation” (p. 400). 19 Peripheral fatigue, such as that seen in skeletal muscle, occurs from a combination of neurological, musculoskeletal, and metabolic aberrations, such as reductions in hepatic or muscular glycogen stores, reduced oxygen consumption during activity, and muscle fiber changes resulting from physical inactivity or aging.

Central fatigue is thought to result from disturbances to the complex neurological circuitry connecting the brain's motor coordination centers (basal ganglia) with the executive center (frontal lobe) and internal motivational center (hypothalamus and limbic system). 20 These neuroregulatory mechanisms are vulnerable to episodes of hypoxia, inflammatory processes, alterations in neurotransmitter release (e.g., serotonin or dopamine), and other central nervous system (CNS) disturbances. Central fatigue differs from peripheral fatigue in that it occurs in the absence of clinically detectable motor weaknesses. Central fatigue has been defined as the “failure to initiate and/or sustain attentional tasks (mental fatigue) and physical activities (physical fatigue) requiring self motivation (as opposed to external stimulation)” (p. 35). 20 Episodes of central fatigue may be of short duration, such as those following viral illnesses or sleep disturbances, but may also persist for many months, as seen in neurological disorders, including Parkinson's disease or multiple sclerosis.

Some believe that fatigue is psychological in origins. However, psychological fatigue has not been adequately defined in the literature. Psychological fatigue symptoms may originate from emotional phenomena or may arise from alterations in neurotransmitter release such as is seen in clinical depression. A recent study of fatigue in primary care patients suggested that psychological disorders were more predictive of fatigue than were physical illnesses. 21 Psychological phenomena not usually treated clinically, including stress and burnout phenomena, have also been associated with increased levels of fatigue.

Fatigue is one of the most common somatic symptoms associated with depression 22 - 26 and is among the nine diagnostic criteria for major depressive disorder as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV). 27 Recently, semi-structured interviews were conducted with 1,523 psychiatric outpatients to reevaluate each of the symptoms for their appropriateness for continued inclusion in the current DSM-IV diagnostic criteria for major depression. 28 The authors predicted that somatic symptoms such as fatigue, insomnia, and impaired concentration would not retain a high enough degree of specificity for diagnosing depression since they are also diagnostic criteria for other illnesses. Contrary to prediction, 87.2% of the subjects reported being fatigued, suggesting that fatigue is a highly sensitive marker of depression. In further logistic regression analyses, fatigue was as strong a predictor of depression as those symptoms considered to be unique to depression. 28

Consequences of Fatigue

Among healthy individuals without diabetes, self-reported symptoms such as fatigue have been found to negatively affect self-rated health and quality of life 28 . Fatigue has also been associated with decreased physical functioning and decreased ability to manage routine daily activities 26 , 29 . While few studies have examined the relationship between fatigue and daily functioning in individuals with diabetes, fatigue is likely a barrier to their health-promoting behaviors, such as participating in diabetes self-care regimens, following a healthy eating plan or participating in regular exercise.

Despite the consequences, fatigue remains a challenging problem for treatment by health care providers. Wessely suggests that because fatigue is a non-specific and universal symptom, clinicians are hindered in appropriately diagnosing or treating the problem 3 . In addition, fatigue researchers have yet to agree on standardized definition, measurement or diagnostic criteria, further hindering our understanding of this symptom. Thus, we undertook this review to move toward creating a framework for beginning to conduct focused studies on fatigue in diabetes.

Fatigue in Diabetes

As in other conditions, fatigue in people with diabetes is likely to be multidimensional, encompassing physiological, psychological, and lifestyle factors ( Figure 1 ).

Exploratory Framework of Fatigue in Diabetes

Physiologic Diabetes-Specific Factors Relating to Fatigue

One likely reason for fatigue in diabetes (uncomplicated by severe comorbidities) is alterations in blood glucose levels. Altered blood glucose metabolism may result in acute and chronic hyperglycemic episodes, hypoglycemia, or blood glucose fluctuations. These alterations may affect fatigue separately or in tandem. The presence of short- and long-term complications of diabetes and their symptoms, including symptoms of hypo- or hyperglycemia, cardiac disease, neuropathy, or retinopathy, has also been associated with increased fatigue 30 - 32 .

Glucose Metabolism

Acute hyper/hypoglycemia.

Some evidence suggests that acute glycemic excursions are associated with fatigue. During an in-depth analysis of common hyperglycemic symptoms, 361 insulin-treated diabetics were asked to list their most common symptoms and report the blood glucose level at which those symptoms occurred 33 . Tiredness was ranked fifth of the 16 most commonly reported symptoms. A mean symptom inventory score was computed for each subject based on the 16 symptoms. There was only a slight association between mean symptom inventory score and chronic glucose control measured by hemoglobin A 1c ( r = 0.149, p < 0.003). However 85% of the subjects were able to estimate a hyperglycemic threshold for the onset of their symptoms (including tiredness). The mean blood glucose threshold was 274 mg/dl, suggesting that acute elevations of blood glucose were more predictive of symptoms, including tiredness. Subjects also reported tiredness during lower levels of hyperglycemia, prior to osmotic symptoms such as thirst or increased urination 33 .

More recently, the effects of acute hyperglycemia on cognition and mood were examined in a group of 20 subjects with type 2 diabetes 34 , and the study concluded that acute episodes of hyperglycemia were significantly associated with diminished cognitive function and altered mood states, including heightened fatigue 34 .

Findings from an epidemiological study of 1,137 general practice patients with newly diagnosed type 2 diabetes revealed that fatigue was present in approximately 61% of patients at the time of diagnosis and was significantly associated with fasting plasma glucose (FPG) levels, but not hemoglobin A 1c 35 . It is possible that the average hemoglobin A 1c may be falsely low in this group because their blood glucose level may not have been elevated the full three months. Similar findings were reported in 430 adults with newly diagnosed type 2 diabetes, prior to enrolling in the United Kingdom Prospective Diabetes Study (UKPDS) 36 . A high number of symptom complaints (including fatigue) was significantly associated with FPG, body mass index (BMI), and female gender. There was no association between symptom complaints and hemoglobin A 1c , again suggesting a stronger association between fatigue and acute, rather than chronic, hyperglycemia.

Acute episodes of hypoglycemia have also been associated with higher levels of fatigue. In a controlled study of adults with type 1 diabetes, the effects of a nocturnal hypoglycemic episode on subsequent subjective well-being and physical fatigue were examined 37 . In this study, blood glucose levels were lowered to hypoglycemic levels (42-59 mg/dl) during one overnight visit, and maintained within a higher range (90-216 mg/dl) during a second overnight visit. The morning following the hypoglycemia visit, subjects reported more fatigue symptoms, decreased well-being, and were more likely to fatigue faster during an exercise bout than when blood glucose levels were maintained within the higher range.

Chronic hyperglycemia

Chronic hyperglycemia has long been assumed to cause fatigue; however, few data support this relationship. One cross-sectional study examined the relationship between glucose control and physical symptoms, moods, and well-being. The study included 188 Dutch patients with type 2 diabetes 38 , and fatigue was measured using two different instruments: the Diabetes Symptom Checklist-Type 2 (DSC-Type 2) 39 and the Profile of Mood States (POMS) 40 . Slight, but statistically significant, correlations between HbA 1c and fatigue were noted using both instruments (DSC-Type 2 r = 0.14, p < 0.05; POMS r = 14, p < 0.05), suggesting that chronic hyperglycemia may contribute to fatigue.

In contrast, there was no association between hemoglobin A 1c and fatigue symptoms as measured by the DSC-Type 2 during a two-year prospective study examining the initiation of insulin therapy in Dutch adults with type 2 diabetes 41 . The authors reported a significant relationship of every unit increase of insulin dose with DSC-Type 2 total symptom complaint scores (which included a fatigue subscale) and POMS anger, displeasure, and fatigue scores, suggesting increased emotional fatigue possibly related to increased hypoglycemic events and the burden of daily injections 41 .

In a study of patients with type 2 diabetes and restless leg syndrome, hemoglobin A 1c was associated with sleepiness (as measured by the Epworth Sleepiness Scale), but not fatigue (as measured by the Fatigue Severity Scale) 42 .

Glucose variability (blood glucose fluctuations)

Glucose variability can be defined as the fluctuations in glucose levels that may occur rapidly over minutes or over hours. In the clinical setting, glucose variability may be missed, since glucose fluctuations will not be revealed through a single measure of blood glucose or with a hemoglobin A 1c test. Fluctuations in blood glucose levels, regardless of overall blood glucose control as measured by hemoglobin A 1c , may contribute to fatigue.

There is evidence to suggest that the frequency and magnitude of blood glucose fluctuations may be greater in individuals with type 1 diabetes, who are more sensitive to the effects of exogenous insulin, have altered glucagon and norepinephrine responses to hypoglycemia, and may overcompensate by overtreating hypoglycemia. These factors place them at higher risk for hypoglycemia and hyperglycemia excursions than patients with type 2 diabetes. 45 However, a growing body of literature suggests that individuals with type 2 diabetes may also experience blood glucose fluctuations. 46 - 48 A study of non-insulin-treated adults with type 2 diabetes ( n = 856), revealed exaggerated postprandial glucose excursions (in excess of 40 mg/dl) from pre-meal blood glucose values in the majority of subjects. These findings were consistent, even in subjects with hemoglobin A 1c values in the satisfactory range (< 7.0%). 46 Recent evidence suggests that these glucose fluctuations during the postprandial period may be strong triggers for inflammatory markers and oxidative stress, thought to play a key role in the development of diabetic vascular complications 43 . Oxidative stress and fatigue were studied in patients with chronic fatigue syndrome. In a control-matched, cross-sectional study of 47 adults with chronic fatigue syndrome, increased markers of oxidative stress, including isoprostanes and oxidized low-density lipoproteins, were associated with chronic fatigue symptoms 44

Glucose variability may also cause psychological fatigue. Patients who frequently experience wide swings in blood glucose levels are likely to feel that they are failing at maintaining good diabetes control. They may feel “worn out” or “burned out” from the daily tasks of diabetes self-management and disengage from performing those tasks. Over a long period of time, this neglect could result in worsening of blood glucose control, thus increasing the risk for long-term complications.

Diabetes-Related Long-Term Complications/Symptoms

Many of the chronic complications associated with diabetes are associated with fatigue. Diabetes is the leading cause of end-stage renal disease (ESRD) in the United States 45 . Anemia, the major side effect of impaired kidney function, results in increased fatigue. Among patients undergoing dialysis for treatment of ESRD, symptoms (including fatigue) negatively affected quality of life and were significantly worse among the patients with diabetes than those without diabetes 30 . Additionally, investigators have suggested that anemia is more prevalent in patients with diabetes than without 46 and occurs during the earliest stages of kidney disease, when only microscopic amounts of urinary protein are present 47 .

Some form of neuropathy (nerve damage) will affect 60%-70% of all people with type 1 or type 2 diabetes 45 . Peripheral neuropathy, which predominantly affects the hands and the feet, is the most common form of diabetic neuropathy. In a study of adults with type 1 and 2 diabetes, foot pain was positively correlated with symptoms of general fatigue ( r = 0.63, p < 0.001), physical fatigue ( r = 0.48, p < 01) and reduced activity ( r = 0.48, p < 01) 32 .

Peripheral vascular disease is often present in patients with diabetic peripheral neuropathy, and causes deep, aching pain in the calves. Inadequate perfusion to the lower extremities deprives the tissues of oxygen, nutrients, and antibiotics, and impairs waste removal, thus placing the limb at risk for impaired wound healing and gangrene. Treatment for lower extremity infections and ulcerations usually includes reduced ambulation or bearing no weight on the affected limb. The combination of poor substrate utilization, infection risk, and reduced physical activity may all contribute to fatigue.

Diabetes-related symptoms, whether or not a comorbid condition has been diagnosed, have also been associated with fatigue. Findings from a study addressing workplace fatigue in 292 individuals with insulin-treated diabetes reported that diabetes symptoms and the burden of adjusting insulin dosages accounted for 29% of the variance in fatigue scores 48 . In a later paper, these authors found that individuals with diabetes and a comorbid condition reported more prolonged fatigue than did either healthy persons or individuals with diabetes and no comorbid condition 31 . Neither paper described the specific diabetes symptoms that were associated with the increased fatigue, nor did either study distinguish between subjects with type 1 or 2 diabetes. Both studies, however, offered additional support that diabetes fatigue may have deleterious effects on job or work roles.

Psychological Factors Associated with Fatigue in Diabetes

The proposed fatigue research framework ( Figure 1 ) suggests that there are two key psychological variables that are most likely associated with diabetes-related fatigue: diabetes emotional distress and depressive symptoms.

Diabetes emotional distress

Mental fatigue associated with managing diabetes's chronic and complicated medical regimen has been termed “Diabetes Overwhelmus” in the lay press 49 . A new term has evolved called “diabetes emotional distress” which represents a sub-clinical field of psychological disturbances 50 , 51 . This term is related to the work of managing and living with diabetes. Diabetes emotional distress, frequently called “diabetes burnout,” has been eloquently described:

Burnout is what happens when you feel overwhelmed by diabetes and by the frustrating burden of diabetes self-care. People who have burned out realize that good diabetes care is important for their health, but they just don't have the motivation to do it. At a fundamental level, they are at war with their diabetes--and they are losing 52 .

Little research has directly linked diabetes emotional distress or burnout to fatigue; however, “lack of energy” and “feeling that diabetes is taking up too much of my mental and physical energy everyday” are measurement items in the instruments most widely used to measure diabetes emotional distress 50 , 53 . From data collected on 87 adults with type 1 and type 2 diabetes, Casalenuovo reported that the stress of living with diabetes was disruptive to well-being and led to energy depletion and fatigue 54 . Multiple regression analysis revealed that stress accounted for 23% of the variance in fatigue ( p < 0.01) 54 . In a study evaluating the influence of initiating insulin therapy on physical symptoms, mood states, general well-being (including fatigue), and treatment satisfaction in adults with type 2 diabetes, subjects reported no changes in physiological fatigue symptoms with improved glucose control 41 . However, psychological fatigue symptoms such as feeling “burned out” increased significantly. The subjects in the intervention group, who were started on insulin therapy, reported more frequent insulin reactions and weight gain. These findings support the relationship between the increased burden of diabetes management and psychological/emotional fatigue, despite improved physiologic blood glucose control.

The concept of burnout has been strongly associated with workplace fatigue. Maslach has conceptualized three key dimensions associated with job burnout: overwhelming exhaustion, feeling of cynicism and detachment from job, and sense of ineffectiveness and lack of accomplishment 55 . These dimensions may be seen in a non-workplace context in patients who experience “diabetes burnout.” When patients with diabetes do not experience positive results from their efforts at diabetes self-management, or when they experience unanticipated or negative results, they may experience a sense of ineffectiveness or lack of accomplishment. Over time, they may experience emotional fatigue, cynicism, and resultant detachment from their health care provider's recommendations. These factors may play a role in exacerbating physiologic fatigue, or adding a psychological dimension to it. This has special implications for individuals with diabetes. There is a growing body of evidence that working-age adults with diabetes are more likely to be unemployed or unable to work, miss work days, or have severe difficulty with work tasks compared to those without diabetes 56 , 57 .

Research has suggested that individuals with diabetes are twice as likely to suffer from depression as the general population 58 . A recent meta-analysis reported that elevated depressive symptoms were present in 11% and major depression was present in 31% of individuals with diabetes 58 . In addition, diabetes has been associated with an increased risk for developing depression or depressive symptoms 58 - 60 , while clinical depression and depressive symptoms have been associated with increased risk for diabetes 61 , 62 . These findings underscore the importance of and challenges to clinical measurement of fatigue in people with diabetes.

Lifestyle Factors Associated with Fatigue in Diabetes

Although numerous lifestyle factors may affect fatigue, being overweight and engaging in low levels of habitual physical activity have been strongly associated with fatigue and have special clinical relevance for many patients with diabetes.

Body mass index

Most people with insulin-resistant type 2 diabetes are overweight or obese 63 . Obesity and overweight have been associated with higher levels of fatigue in the general population 64 - 66 , and were independently associated with fatigue levels in women 65 . The physiological and psychological phenomena that mediate the relationship between obesity and fatigue have not been fully elucidated; however, there is a growing body of literature suggesting that increased levels of pro-inflammatory cytokines (as seen in obese individuals) may be significant factors in fatigue levels 67 - 69

Physical activity

There is growing interest in the relationship between self-reported feelings of fatigue and physical activity. Much evidence supports the positive effects of regular physical activity on alleviating symptoms of fatigue 70 - 73 . Physical activity has been inversely associated with reported fatigue levels in diverse populations, including patients with cancer 74 , rheumatoid arthritis 75 and chronic diseases, including diabetes and hypertension 76 . A secondary analysis of data collected from the Third National Health and Nutrition Survey revealed that adults aged 20-59 years who reported low levels of physical activity were more likely to feel “tired” or “exhausted” despite a usual night's sleep 64 . In healthy, physically fit individuals who were exercising approximately six hours per week, cessation of usual exercise routines resulted in increased levels of fatigue 77

There are several etiological mechanisms that might explain the relationship between physical activity and fatigue in individuals with type 2 diabetes. Regular physical activity, especially vigorous physical activity, has been shown to improve aerobic capacity and muscle mass, enhance metabolic substrate use for energy, and improve mood. It has been noted that individuals with diabetes engage in low levels of physical activity 78 - 82 , which may lead to reductions in aerobic capacity.

The Effects of Fatigue in People with Diabetes

Fatigue was among the top four symptoms found to interfere with self-reported quality of life in women with type 2 diabetes who rated their health poorer than women without symptoms 83 . In children with type 1 diabetes, self-reported fatigue was comparable to fatigue in children with cancer and significantly higher than in healthy, age-matched controls 84 .

Qualitative research has been the primary source of recurring themes about the deleterious effects of fatigue in adults with diabetes 85 - 90 . For example, African-American women with type 2 diabetes participating in a qualitative study of problem-solving in diabetes self-management noted that fatigue limited their ability to exercise 85 . Phrases such as “overwhelming tiredness,” “sleeping through most days,” and “I can't do what I want, I feel weak…I am lonely” were expressed by women with type 2 diabetes living in Australia who participated in a qualitative study about the experience of living with a chronic illness 86 . Fatigue was among the predominant concerns in the Australian women, who also reported that they had limited their social activities and/or confined their activities to only those deemed necessary 86 . In a focus group about the barriers to diabetes self-management, feelings of being betrayed by the body were common among rural-dwelling African American adults with type 2 diabetes. A male participant in the focus group described himself as “so tired it was like my muscles weren't working properly” 88 . In community-dwelling adults with type 2 diabetes, both sleepiness and being tired were associated with lack of motivation and ability to perform such diabetes self-care activities as preparing healthy meals, participating in exercise, and monitoring blood glucose levels 90 . In all of the above-referenced studies, the participants noted feeling that they were no longer able to participate in activities and attributed their fatigue to their diabetes 85 - 89 .

Such findings suggest that fatigue has far-reaching and serious consequences for patients with diabetes because it is largely a self-managed disease, requiring both physical and mental energy to accomplish the daily self-management tasks necessary for maintaining optimal health.

The Need for Studies on Fatigue in Diabetes

A recent review of diabetes randomized clinical trials revealed that only 18% of studies included measurement of patient-important outcomes, such as symptoms or health-related quality of life in their study designs 91 . One study that did include such patient-important outcomes provided us with some of the most directly applicable findings on this subject to date. Skelly reported that symptom-focused education improved self-management practices and Hb A1c levels. The subjects also had higher perceived quality of life and reduced symptom distress 92 . Further studies such as this can only increase the much-needed understanding of fatigue in diabetes.

A Working Model for Research in Fatigue in Diabetes

Based on the review of the above studies related to fatigue in diabetes and the identified need for more studies and a more directed approach, we propose a model ( Figure 1 ) for more focused research on this important symptom and its meaning for people with diabetes. Fatigue in people with diabetes is likely multidimensional, incorporating any combination of physiological phenomena such as altered blood glucose levels and diabetes complications; psychological phenomena, such as depression or diabetes-related emotional distress; or lifestyle factors, such as being overweight or physically inactive.

Patients with diabetes who neglect their health because of symptoms such as fatigue put themselves at greater risk for both the acute and chronic complications associated with diabetes. The successful self-management of diabetes requires physical, psychological and cognitive tasks (e.g., exercise participation, management of hypoglycemia and hyperglycemia, and calculation of insulin doses) that are likely to be affected by fatigue. Fatigue in diabetes is likely caused from the interplay of physiological, psychological, and lifestyle-related factors. Fatigue is also likely to be both a cause and a result of poor diabetes self-management. Diabetes and its related effects represent a potential archetype for fatigue, with abundant potential for future research.

Acknowledgments

This research was funded in part by the National Institutes of Health/National Institute for Nursing Research F31 NR009751. The authors thank Kevin Grandfield for editorial assistance.

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Diabetes burnout among emerging adults with type 1 diabetes: a mixed methods investigation

Affiliation.

• 1 Psychology Department, Carnegie Mellon University, Pittsburgh, PA, 15213, USA. [email protected].
• PMID: 33566266
• DOI: 10.1007/s10865-020-00198-3

Feeling overwhelmed, exhausted, and frustrated by the daily demands of diabetes management has been referred to as diabetes burnout. The goal of the study was to develop a measure of diabetes burnout and to link this measure to psychological health and diabetes outcomes. Emerging adults with type 1 diabetes (n = 88, average age 27) completed an online questionnaire and an HbA1c assessment; a subset was interviewed by phone to obtain a more in-depth understanding of burnout. Exploratory factor analysis revealed three burnout domains: exhaustion, detachment, and powerlessness. Burnout was related to higher psychological distress, higher diabetes distress, and poorer diabetes outcomes. Burnout independently predicted higher HbA1c, independent of diabetes distress. Qualitative interviews revealed that participants defined burnout in terms of exhaustion and powerlessness and resolved burnout by acceptance and utilization of social resources. Prevention and intervention efforts might target resilience as a way to mitigate burnout.

Keywords: Burnout; HbA1c; Psychological distress; Type 1 diabetes.

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September 12, 2024

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Fear of hypoglycemia remains a major barrier to exercise among adults with type 1 diabetes, research shows

by Diabetologia

Despite high use of continuous glucose monitoring and insulin pump therapy, fear of hypoglycemia (low blood sugar) remains a significant barrier to physical activity and exercise for adults with type 1 diabetes (T1D), according to new research presented at the Annual Meeting of The European Association for the Study of Diabetes ( EASD ), held in Madrid (9–13 Sept).

However, the findings suggest that if exercise and diabetes management are discussed in the clinic, this fear could be reduced.

"Regular exercise can help individuals with diabetes to achieve their blood glucose goals, improve their body composition and fitness, as well as reduce their risk of heart attacks and strokes, which is higher in people with type 1 diabetes," explained lead author Dr. Catriona Farrell from the University of Dundee, Scotland, UK.

"Yet many people living with type 1 diabetes do not maintain a healthy body weight or manage to do the recommended amount of physical activity each week."

A number of previous studies have examined barriers to exercise in T1D, but these have been limited by their small sample size.

To fill this important evidence gap, researchers from the University of Dundee assessed knowledge and barriers to physical activity in adults with T1D and associated predictive factors.

Adults with T1D were recruited from the NHS Research Scotland Diabetes Network (research register) and internationally via social media.

Overall, 463 adults, 221 men and 242 women, with T1D answered an anonymous web-based questionnaire to assess barriers to physical activity (measured on the modified Barriers to Physical Activity in type 1 Diabetes [BAPAD-1] scale), diabetes management, and attitudes to exercise and sport.

Participants were asked to rate on a 7-point Likert scale (1, extremely unlikely to 7, extremely likely) the chance that each of 13 factors would keep them from doing regular physical activity in the next six months. Factors included: loss of control over diabetes, the risk of hypoglycemia, the fear of being tired, the fear of getting hurt, a low fitness level, and lack of social support.

Researchers calculated average scores for each factor and assessed which were most correlated with perceived barriers to physical activity, as well as identifying independent predictors.

The participant reported median age of respondents was 45–54 years, median disease duration 21–25 years, and median HbA1c 50–55 mmol/mol (an ideal level is 48 mmol/mol or below).

Over three-quarters (79%) of respondents reported using continuous or flash glucose monitoring, around two-thirds (64%) said they were treated with multiple daily insulin injections, and over a third (36%) reported using insulin pump therapy.

The researchers identified that despite advances in technologies and diabetes management , risk of hypoglycemia with exercise remains a significant barrier to physical activity.

Importantly, participants who best understood the importance of adjusting insulin dose before and after exercise as well as adjusting carbohydrate intake for exercise were found to be less fearful of hypoglycemia associated with physical activity. This knowledge is essential in order to adapt insulin and/or carbohydrate intake to prevent hypoglycemia induced by exercise.

The researchers also found that being asked about exercise or sport within a diabetes clinic was negatively correlated with fear of hypoglycemia, and identified exercise confidence as the strongest independent predictor of fear of physical activity.

"Our findings demonstrate that in order to break down the barriers to physical activity, and empower our patients to exercise safely and effectively, we need to improve the education we provide and our dialogue about exercise in clinics," said Dr. Farrell.

"In turn, this should help them to achieve the multitude of health benefits that exercise offers."

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Weekly insulin injection as effective as daily injections in type 1 and type 2 diabetes, research suggests

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A once-weekly injection of insulin is as effective as daily injections for blood sugar management in both type 1 and type 2 diabetes mellitus (T1DM/T2DM), studies have suggested.

In a phase 3, non-inferior study, published in The Lancet on 10 September 2024 , 692 adults with T1DM were randomly assigned to receive either once-weekly insulin efsitora (n=343) or once-daily insulin degludec (n=349), both in combination with insulin lispro.

The study aimed to assess the efficacy and safety of efsitora compared with degludec by measuring the change in glycated haemoglobin (HbA1c) and incidence of severe hypoglycaemia during the 52-week study period.

At week 26, researchers found that mean HbA1c decreased from 7.88% (62.66 mmol/mol) at baseline to 7.41% (57.5 mmol/mol) with efsitora, compared with 7.94% (63.3 mmol/mol) at baseline to 7.36% (56.9 mmol/mol) with degludec — a mean change of -0.51% with efsitora and -0.56% with degludec — confirming a non-inferiority margin of 0.4% for efsitora compared with degludec. 

However, the incidence rate of moderate or severe hypoglycaemia with efsitora compared with degludec was 14.03 versus 11.59 events per patient-year of exposure — an increased risk of 21%, which was statistically significant.

The incidence of severe hypoglycaemia was also reported more frequently in the efsitora cohort at 10% (n=35/343), compared with degludec at 3% (n=11/349), during the 52-week period. Hypoglycaemia was reported more frequently in the first 12 weeks of the trial.

The authors noted that while efsitora showed non-inferior HbA 1c  reduction compared with degludec, the greater incidence of severe hypoglycaemia in participants treated with efsitora may “suggest the need for additional evaluation of efsitora dose initiation and optimisation in people with type 1 diabetes”.

Another phase 3, non-inferior study, published on 10 September 2024 in the New England Journal of Medicine , included 928 participants with T2DM, who were randomly assigned to receive either efsitora (n=466) or degludec (n=462) over 52 weeks.

At week 52, researchers found that mean HbA1c decreased from 8.21% at baseline to 6.97% with efsitora (−1.26 percentage points) and from 8.24% to 7.05% with degludec (−1.17 percentage points), with an estimated treatment difference of −0.09 percentage points, demonstrating non-inferiority of the weekly injection.

The T2DM study also observed an incidence rate of moderate or severe hypoglycaemia with efsitora compared with degludec at 0.58 versus 0.45 events per participant-year of exposure; however, these findings were not statistically significant.

Commenting on the studies, Philip Newland-Jones, consultant pharmacist in diabetes and endocrinology at University Hospital Southampton NHS Foundation Trust, said: “Once-weekly insulin has the potential to support in those patients who have insulin resistance in T2DM and require similar background doses of insulin daily. 

“There are possible groups that may benefit from once-weekly dosing, such as those requiring district nurses; however, there are also potential risks to take into consideration in this group,” he added.

“I believe that in line with data for insulin icodec once-weekly insulin, these data confirm that these insulins are unlikely to be used widely in T2DM because of the increased risk of hypoglcyaemic episodes compared with standard care. 

“This is likely to be due to the differing daily requirements and flexibility in insulin required in the management of T1DM, further highlighting the benefits of hybrid closed-loop insulin systems, which can vary background insulin requirements,” explained Newland-Jones.

Similar to insulin efsitora, insulin icodec is a once-weekly injection, which is currently under review for regulatory approval for treatment of T2DM . However, it has also been associated with an increased risk of hypoglycaemia.

Guidance from the National Institute for Health and Care Excellence on icodec is expected to be published in May 2025.

Also commenting on the studies, Katie Bareford, senior clinical advisor at Diabetes UK, said: “Keeping blood sugars in target range with insulin therapy can be relentless and exhausting.

“A reduction in the number of insulin injections could lessen the burden of living with diabetes and better support people in their efforts to manage their diabetes.

“We welcome these findings and look forward to further research on once-weekly insulin injections to ensure they are safe and effective for everyone who could benefit,” she said.

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