The Surprising Connection: Diabetes, Depression, and Autoimmune Issues

Foreign. I'd like to welcome everybody. Today's presentation on diabetes, depression and autoimmune issues, examining the interconnection. This is part of Diabetes Awareness Month. I AM your host, Dr. Donnelly Snipes. In this presentation, we're going to start out, I'm going to give a high, high level overview of diabetes type 1 and type 2 so we understand what they are, because a lot of us have heard about it, have had relatives with it, but may not know a lot about, you know, what exactly is diabetes. And then we'll explore the overlap between diabetes, depression and other autoimmune issues and talk about why. As mental health clinicians and social workers, we care, you know, obviously we care about others, but how can this information help us in practice? Diabetes, in just the most layman's terms, is a blood sugar imbalance. Insulin is a hormone that helps the body cells use blood sugar for energy. So if there's not insulin, then our body cells have difficulty taking up that blood glucose to use it for energy. So it's necessary for us to have energy. Lack of insulin means inability for the body to effectively metabolize the blood sugar, which can lead to high blood sugar. So you have the cell and you have blood sugar that gets dumped when we need energy or when the HPA axis is activated and it's just circulating through the system. But unless insulin comes along, insulin needs to be there to open the door to the cell for the blood sugar to get in. You know, grossly oversimplified, but you get the idea. Insulin levels may be out of balance because of destruction of beta cells in the pancreas. Now, this is most commonly what we think of with type 1 diabetes. And this is an autoimmune condition. Now, autoimmune conditions, if you remember, always involve inflammation and nearly always, if not always, are exacerbated or made worse by stress or too much blood sugar. So you may have destruction of the beta cells so that the pancreas just can't produce enough insulin, or you may have too much blood sugar coming in or insufficient production of insulin for some other reason, or insulin sensitivity. And we're going to talk about each one of those in depth. But basically you have too much blood sugar coming in and flooding the system. This can be caused by thyroid dysfunction, hyper or hypothyroid, which, guess what, is an autoimmune condition, HPA axis overactivity. And that can cause inflammation. And it can also be caused by inflammation. Emotional distress, we know, triggers that HPA axis. It triggers the fight or flight reaction. So what happens? Cortisol, adrenaline, norepinephrine are dumped. That causes the dump of blood glucose. And so when our HPA axis is activated, our blood sugar goes up. Even if we're not eating, our blood sugar goes up because it pulls from those stores in the liver. And sleep deprivation. They've actually found that when healthy people are sleep deprived for an extended period that their body behaves much more like someone who is insulin resistant. The body doesn't respond to insulin in the same way. The same thing is true, or a similar thing is true in people with diabetes. When they're sleep deprived, their body reacts worse for, for simplicity, to insulin. It's not as responsive to insulin, which means blood sugar is harder to control and stays higher longer. So sleep, sleep, hygiene and stress management are super duper important concepts for, for diabetes management and prevention. And eating habits, eating processed food, I. E. Comfort foods or continual eating, grazing. Whether you're eating to self soothe or it's just a habit that you like, you eat a lot, or you just like to eat and you eat a lot. If your body is constantly digesting food, you eat first thing when you get up in the morning, you eat all day long, you eat right before you go to bed, you sleep a couple of hours, you get up and you started again. Your, your cells don't get a break from being exposed to insulin. They don't get a break from being exposed to blood sugar. And just like anything else, whether it's dopamine or cortisol or insulin, if your cells are exposed to it for too long, the cells go too much, I need a break. So they become less responsive. They become less willing to open their doors to, to the knock from the dopamine or the insulin and, or the cortisol. And that's what we call resistance. Insulin resistance. Or in addiction terms, we call it tolerance. Same sort of thing, we call it tolerance when it's an addictive drug and we call it resistance when it's a, you know, not addictive, a hormone or something, I guess. But they're basically the same thing. The cells become less responsive and it require more of the same chemical to get the same reaction. So the body, when, when you have insulin resistance, it requires the body to produce more insulin in order to finally get that door to open. Diabetes type 1 is typically thought of as juvenile onset diabetes, but that is really misleading. It's usually diagnosed in children, teens and young adults, but it can develop at age, any age. And I want you to realize this and, and Diabetes itself can d develop at any age. And, and I'm going to jump ahead of myself. Nearly 35% of people in the United States have pre diabetes and that pre diabetes can develop into diabetes at any point. And a lot of them don't realize they have pre diabetes. So when we're working with people, regardless of their age, if they seem like they've got some symptoms of diabetes or may have high risk factors, you know, we want to make sure that they're seeing their physician regularly because their physicist physician is obviously going to be, you know, noting that in the annual physical screening for it, doing everything that they knew need to do. And whether it's Type 1 or Type 2, to us as mental health clinicians, it really doesn't matter. We know that the person is having difficulty managing their blood sugar and that has all kinds of reciprocal effects, negative effects, you know, blindness and, you know, pain and loss of limbs and lots of other things that can be really, really bad complications of diabetes. So if we notice these things, we don't want to, we don't need to get into the weeds. We just need to make sure that we provide a referral. So diabetes type 1, like I said, can occur in any age, usually occurs and is diagnosed in early life. Now remember young adults, that goes up to like 25, 30, depending on how you define it. So that for a lot of us, we're still, we're considering a lot of those people, actual adults. It's caused by an autoimmune reaction that destroys the beta cells in the pancreas, which prevent or hamper the body's ability to make insulin. Another thing that can activate inflammation in the pancreas and pancreatitis is alcohol consumption. I've had a couple clients who have developed really severe pancreatitis and ended up developing diabetes as a result of long standing or, or severe alcoholism. And they weren't really all that old, but they'd been really drinking heavily for several years. Other autoimmune issues like fibromyalgia, lupus, multiple sclerosis, eczema, rheumatoid arthritis, and the list goes on, increase the risk for type 1 diabetes actually for either type of diabetes because they're now recognizing, and I'm getting ahead, but they're now recognizing that type 2 diabetes also has an autoimmune component to it as well. So if somebody has an autoimmune condition, it means their immune system has started attacking healthy tissues. It's kind of gone haywire and it's recognizing healthy Tissues as invaders. Well, if your immune system is already haywire and you know you have one autoimmune disease, it is very, very, very, very common to develop multiple other autoimmune conditions. Especially if the conditions exacerbating that autoimmune issue aren't brought under control. The nutrition, the sleep, the stress management and any mood issues that, that exist, whether they are cognitive in nature or genetic because of maybe, you know, a family history of low serotonin or something. We need to bring, look at the risk factors that increase the activation of that HPA axis and make sure we're bringing that under control and help people develop healthier eating habits and lifestyle habits. And for us that can mean breaking, helping them break the habit of constantly eating. And we would need to work, obviously if they've got diabetes already, we need to work with their physician and or dietitian because we don't want to tell them not to eat when they do need to eat to keep their blood sugar up. Everybody's a little bit different but you know, we can be an integral part of the multidisciplinary treatment team helping people learn how to eat for hunger and eat healthfully and you know, periodically instead of grazing or eating for self soothing. And that can be a big help, that can be a big behavioral help in the treatment and prevention of diabetes. The diabetes type 2 insulin resistant cells impacts about 10% of the population. It also may be autoimmune in nature. Now some of the risk factors, overweight and obesity due to eating habits which result in a nearly constant flow of insulin or frequent insulin spikes is a risk factor for type 2 diabetes. So your, the person's pancreas and the beta cells may be, but they may develop insulin resistance as a result of eating habits. And again, circadian rhythm disruption, sleep disruption is big. I did learn when I was doing this presentation and I'm not sure why I didn't do a deep dive on it. But apparently when we're sleeping our blood sugar, just like we know that our cortisol levels rise dramatically right before we wake up. To help us, you know, wake up, our blood sugar also surges early, early in the morning. And so I thought that was kind of interesting. You know, just kind of a side note, when your cells are consistently exposed to insulin or exposed to frequent floods of insulin, such as, you know, you're going along, you're eating sporadically, but when you do eat, what you eat is half of a birthday cake, you know, that is going to dump that those simple sugars are going to cause that blood sugar, your blood, blood sugar to go way, way up, which causes the pancreas to have to dump a whole bunch of insulin to deal with all that excess blood sugar. So when the cells are constantly exposed, they become less sensitive to insulin's presence, which they call insulin resistance. Consequently, the pancreas makes more insulin to try to convince the cells to respond. Eventually, the pancreas can't keep up. You know, the cells become more and more resistant to that insulin. They say, no, we don't want to open the door. And the pancreas just runs out of gas. It can't keep up and produce enough insulin to convince the cells to open up. So blood sugar rises, setting the stage for type F prediabetes and type 2 diabetes. Symptoms of blood sugar imbalance include hyperglycemia, too much blood sugar and hypog, hypoglycemia, too little blood sugar. Either one is a problem and can have significant physiological problems. If you work with clients who have diabetes or pre diabetes, and chances are you do, it's important to recognize the signs of hyper and hypoglyce glycemia to be able to a differentiate it from something else as you know, as in terms of behavior or intoxication or something like that, as well as to be able to make sure that the person gets the adequate interventions. Too sweet. So hyperglycemia, too much blood sugar. So for this you're not going to want them to be drinking orange juice or something with sugar because they already have too much blood sugar, they need more insulin. When people are hyperglycemic, they have increased thirst, frequent urination, headaches, difficulty concentrating, blurred vision, fatigue, a weak and tired feeling, weight loss, or a blood sugar of more than 100, 180 milligrams per. I believe it's deciliter of blood. So a blood sugar of over 180 is hyperglycemic. If it gets over 200, you know, you're really getting high. I've worked with people who've occasionally spiked into, you know, much, much higher than that. And that's very, very dangerous for the body. It's almost like having too much glutamate. It can become neurotoxic at a certain point. So it's important that we recognize that too much blood sugar is a bad thing. It's not just giving somebody more energy. So in this case, the person really needs insulin. And if they're not already on insulin, they may need medical attention quickly. And what the things that are bolded Here, difficulty concentrating, fatigue, weak, tired feeling, weight loss, and sometimes blurred vision or headaches. If you have a client that starts complaining of these things and says, you know, yeah, they are happening a lot more frequently and I'm just not feeling, feeling well, it's really important that they start monitoring their blood sugar or preferably go and see a doctor. Blood sugar monitors can be bought over the counter. They're obviously not as, you know, super sensitive as the ones in the doctor's office. But if somebody wants to monitor their blood sugar, I know my husband does, they can do it at home. And if they find that their blood sugar is more than 180 or even over getting close to 180, when they start having these symptoms, that tells them that it's probably a good idea to go get evaluated by a physician. So those things are really important to be aware of. When people are intoxicated or going through detox, even, you know, the first couple of months when the body's adjusting, their blood sugar is much harder to control. So if you work in a setting or with people who are recovering from addictions, it is really important to be aware of signs of hyper and hypoglycemia because they do occur. And, you know, hopefully if you're working in a clinic, you have a nurse, lpn, cna, somebody on staff who is able to test their blood sugar if it seems like it's out of whack, and make the appropriate referral. Now, hypoglycemia, people who are hypoglycemic, you don't have enough blood sugar. Remember, our cells need blood sugar to function. So if we don't have enough blood sugar to function, our body starts to freak the freak out. It starts to say, hello, I need fuel or I'm not going to be able to run. Which means the HPA axis kicks off. When the HPA axis kicks off, it dumps glutamate, it dumps norepinephrine, it dumps adrenaline. So people may start feeling nervous and anxious, shaky. That threat reaction, the threat response is happening and it makes sense. You know, it's a survival mechanism. They can become angry or irritable. The lower their blood sugar gets, the more it's a physiological crisis and the more that HPA axis is going to be like, hey, somebody find some blood glucose somewhere. People can also start feeling depressed. When you don't have enough blood sugar getting into the cells to make keep things going, guess what? You start feeling kind of sluggish. Makes sense. You know, a lot of US have had minor, minor mild hypoglycemia at one time or another. And you can probably remember what that felt like. Well, multiply that for people who are experiencing extreme hypoglycemia. My husband is hypoglycemic and when his blood sugar drops, oh boy, it drops. And you know, I can usually tell by his demeanor what's going on. But he can go from being very, he's very, very level, extremely level, especially compared to me. But when his blood sugar drops, he gets to be very snippy and, and, and cranky and, and we, we learned that, you know, thankfully 20 some odd years ago. So he knows what to do and he keeps, you know, glucose tablets with him in case his blood sugar starts to drop. But it's important that people are aware of what it looks like for them when their blood sugar starts to drop. Another interesting side effect of hypoglycemia, some people experience sweating, chills or clamminess. This is another physiological reaction. They're going to have difficulty concentrating. Well, guess what? The brain uses glucose in order to function. When we're thinking, we're burning through blood glucose. So if you don't have blood glucose, it's going to be harder to concentrate. Hunger or nausea. Well, makes sense. When you don't have enough blood sugar, your body's going to be saying, hey, eat something stupid. Blurred vision is very common, as is again weakness or fatigue, which goes along with that. Depression cells aren't getting enough fuel. Eventually they're going to start puttering out or stuttering out just like, you know, anything when it runs out of fuel. So we do want to pay attention to what those signs are just because, you know, you may be in a session with a client or be in group or, you know, when I worked in residential, it wouldn't be uncommon for somebody who is, you know, re relatively even keeled to all of a sudden become angry, irritable, moody. And it was really important to assess, not just to dismiss it and go, oh, that's, you know, post acute withdrawal they'll be fine. They're just, you know, having a moment. But to also assess the physiological issues that are going on with that person to make sure that they don't have something going on with their blood sugar that needs, needs attention. And that's one of those ethical issues. Yes, we don't diagnose it, yes, we don't treat it. But it is important for us as clinicians to be able to screen for it and refer the person to appropriate care Risk factors for hyperglycemia, too much blood sugar, stress. Anything that activates that HPA axis can trigger the dump of blood glucose. So our body can fight off either whatever we perceive as the threat or the actual threat, like a, a physical illness, foreign invader, even like parasites and stuff we get can trigger that HPA axis. There's a lot of stuff that triggers that HPA axis. So we want to take a look at that. As clinicians, we can help people develop good health behaviors that help them keep their HPA axis health and learn how to modulate it through, you know, good health behaviors as well as distress tolerance and emotional regulation skills. If somebody misses their dose of insulin, well, obviously don't have enough insulin, then the cells can't take up the blood sugar. So bada bang if they eat too many carbohydrates for the amount of insulin administered, unfortunately. And I don't know if it's changed much recently, but I know my grandfather in law has insulin or has diabetes and he has to take insulin for it and he very frequently doesn't do the math right anymore. So that causes a lot of problems in helping him manage his insulin levels. My aunt has diabetes and she has a pump so she doesn't have to pay as much attention to it, but that pump doesn't always work. So it's important also to recognize that people with insulin pumps, you know, or who, who self administer insulin, they may not do the math right, or the pump may malfunction or not do the math right, so to speak. And the person may not get enough or may get too much insulin, which can lead to hyper or hypoglycemia. So we don't want to assume that just because they know they've got it and they're trying to treat it, that they are adequately treating it. Additionally, if they eat too many carbohydrates, for example, that could increase their insulin levels. And if they're under stress, maybe they're stress eating comfort food. So had a really bad day and they decided to, you know, go have a piece of pie and a beer. You know, that's just like adding insult to injury when you put alcohol with it. But you know, that's just going to throw a whole different calibration into how much insulin they need and how their body handles it. If somebody, and this is interesting, becomes inactive or exercises less than usual, it can cause them to have hyperglycemia. Their body's used to requiring a certain amount of energy and all of a sudden this person, because of Illness because of bed rest, because of COVID For whatever reason, they've become much less active than us Usual, they can develop hyperglycemia and. And it's important for them to really closely monitor their insulin levels and their blood sugar levels. If their activity levels are altered for some reason, oftentimes changes in activity levels also coincide with stress of some sort. So we don't want to minimize the impact of stress. And while we may not be able to, as clinicians address what's going on, that's keeping them from being less active. If they broke their leg or, you know, if, you know, whatever, we can help them modulate, you know, work with their cognitions to maybe modulate and regulate their emotions a little bit better so they're not keeping that HPA axis totally revved. People who take part in strenuous physical activity, especially when their blood sugars are high and insulin levels are low, are at a greater risk for hyperglycemia. I thought that was interesting. That seemed kind of counterintuitive. But the take home, what you really need to pay attention to is strenuous physical activity causes the body to burn through a bunch of blood sugar. But strenuous physical activity is perceived as a fight or flight scenario in the body, and it increases cortisol levels, which also increases blood glucose. So if somebody is working out really intensely, it may cause a blood glucose dump, which can lead to hyperglycemia. Being aware of your clients who may be power lifters or. Gosh, I can't think of it. The big box exercise right now. Somebody help me with that. Or, you know, anything that is super intense. CrossFit CrossFitters do really intense exercise, and sometimes that can cause a significant spike in blood glucose as a result of the intense effort. Additionally, certain medications like corticosteroids can cause hyperglycemia and something that is called steroid induced diabetes, which can resolve soon after the conclusion of steroid treatment. Now you're thinking steroids. You're like, well, that's. Why would somebody be on a long course of steroids? Not uncommon in treatment of cancers. Not uncommon in the treatment of autoimmune issues, because steroids reduce inflammation. So if somebody is taking steroids, it also wasn't uncommon. And this is probably a complicating factor. I'm just speculating in Covid. Remember with COVID there was a lot of systemic inflammation and a lot of inflammation in the lungs. So people were being put on corticosteroids like prednisone in order to try to Reduce the inflammation in their lungs, and those steroids are going to affect blood sugar levels. And so the people who had covet and had diabetes, you know, that was a balancing act that the doctors were constantly having to drug juggle and thyroid dysfunction, hyper or hypothyroid dysfunction, interestingly enough, both contribute to hype hyperglycemia. And about 10% of people in the United States have some level of thyroid dysfunction. Additionally, thyroid dysfunction in most cases is also considered an autoimmune issue. So we're seeing how these things go together. If you have a dysfunctioning thyroid from an autoimmune condition, you've already got some inflammation going on, then you're at greater risk for developing another autoimmune issue. Diabetes and thyroid dysfunction alters blood sugar levels, which also makes it more likely that one of the secondary autoimmune issues you're going to develop is, guess what? Diabetes. Now, they do find that in some places, especially less developed countries, but a little bit more lately in the United States, iodine insufficiency contributes to thyroid dysfunction. And once people start getting enough iodine, their thyroid starts functioning much, much better. This switch from iodized table salt to sea salt has actually contributed to the development in the United States of a significant portion, not a majority, but a significant portion of people having some level of iodine insufficiency. You don't need a whole lot, which is why you could get it from table salt. But so a lot of multivitamins have started adding iodine. Hyper hypoglycemia risk factors, increased age. Well, we can't do anything about that. Underactive thyroid can, can contribute to hypoglycemia, sometimes kidney damage, skipping meals, or erratic eating, as we see in people who have high levels of anxiety or depression, we see alterations in eating and weight. Drinking alcohol can contribute to hypoglycemia. Heavy exercise can contribute to hypoglycemia. So you don't know with heavy exercise whether the person's going to have hypoglycemic reaction by, you know, burning through their blood sugar, all the blood sugar that they've got in their system, or if they're going to get to the point where they have a major dump of blood sugar. Beta blockers, which are often used for blood, high blood pressure can cause symptoms of depression, and they can also cause hypoglycemia. So if you have patients who are on blood pressure medications, be aware that that's a risk factor if they're on blood pressure medications and diabetic Be aware that that is a confounding risk factor. And drum. Oh please. Antidepressants. The pancreas, where those beta cells are, where the insulin is made, communicates with the brain through serotonin signaling and the vagus nerve. When people are on antidepressants, it alters their level of serotonin and alters the serotonin signaling. People who are on antidepressants typically don't have sufficient serotonin. Not always. There's, there's a lot of other reasons for it. But you know, in about 30% of people with, with depression, serotonin may be one of the main culprits. And when that's the case, it alters the pancreas's ability to communicate with the brain about blood sugar, blood glucose levels and the need for, or lack of need for insulin. So serotonin disruption or alterations actually can contribute to difficulty managing blood sugar. Take home message. If we've got a client who is, has diabetes or pre diabetes and starts taking antidepressants and they start having symptoms of hypoglycemia, it's important for them to be aware of, you know, what may be going on because that is super, well, relatively easy to address. If the antidepressants are helping them feel better, mood wise, you know, they need tools to address their hypoglycemia and their doctor or their nutritionist can help them with that. But we do want to help them understand when they start taking antidepressants, you know, that there could be a myriad of things that are causing some of the side effects they're feeling, especially if those side effects don't go away in the first couple of days. Most antidepressants, when people start taking them, the first two or three days can be pretty dicey. People tend to feel a little bit unwell, but then they start feeling better. And if your clients aren't feeling better or if they do have, you know, they have diabetes, that's, that's a really important piece of information. I know I have worked with psychiatrists in the past who haven't assessed for that. You know, they've just done a general, you know, what's your mood, what's your mood history, what's your depression history, family history of mental health issues. Okay, here's an antidepressant without screening for things like diabetes that could be negatively impacted or impacted by antidepressant treatment. Autoimmune issues. As I said before, a lot of times when people have one autoimmune issue, they have multiple. Because once the auto. Once the immune system starts to go haywire, you know, it just kind of cascades in. Autoimmune issues. Remember, the body is misidentifying healthy tissue as a pathogen, and it attacks it. The immune system is designed to clear out, you know, cells that have died or have mutated. They find things that don't belong or are not working well, and they clear them out in order to make the body safe and efficient. It's a great system when it's working. Risk factors for autoimmune issues. Guess what? Our old friend HPA axis dysregulation, which is so common in people with depression, ptsd, anxiety, inflammation. So HPA axis dysregulation can lead to inflammation, and inflammation can lead to activation or increased activation of the HPA axis, which can lead to causing the brain, the body, to dump too much blood sugar. So you end up with hyperglycemia. And the body can develop insulin sensitivity when it's constantly being bombarded. So what causes that HPA axis dysregulation? You know, we've gone through these before. Stress, ptsd. Very common in ptsd. We have talked in other classes about how the persistent HPA axis dysregulation and hypervigilance in PTSD often leads to hypocortisolism. Now remember, hypocortisolism is like cortisol resistance, so to speak. When the body is exposed to cortisol, the stress hormone, consistently for too long, eventually it starts saying, I, I can't. I need a break. So it becomes less responsive to the cortisol. So the body responds by ramping up the amount of cortisol. Eventually, the body can't produce enough cortisol to get the cells to respond with the stress reaction, or at least to most stressors, which is when people start feeling depressed. So hypocortisolism is not uncommon. When you start seeing people who are anhedonic and maybe withdrawn and seem to be less anxious and irritable and more flat and depressed. In depression, the HPA axis, interestingly enough, is continually up, regulated. Up regulated from the distress. So people typically don't just start out being depressed. Not always, but there is a very large proportion of people who have depression who initially felt helpless, hopeless. Anxious helplessness and hopelessness. Very trademark characteristics of depression. Well, when an organism is helpless and hopeless, what does that mean? They're vulnerable. What does vulnerability mean? Threat. What does threat mean? HPA axis activation. Fight or flee. So in depression, the HPA axis is continually upregulated which leads to desensitization of those cortisol receptors, which leads to increased activity of the inflammatory cytokines, the immune system, basically, and disturbances in neurotransmitter functioning. We've talked in other classes about the HPA axis and how norepinephrine, dopamine, serotonin, and hormones like estrogen and testosterone and your thyroid hormones are all involved in that process. So when that system goes wonky, the transmission of those and the balance of those neurotransmitters also goes wonky. Other autoimmune issues can upregulate that HPA axis because remember, autoimmune by, by its very definition involves inflammation. And inflammation is always perceived by the body as a threat. Certain viruses, like at the Epstein Barr virus, which is one of the ones that produces mono or the one that produces mono and alcohol consumption. Alcohol is very inflammatory to our body. If you've ever drank, you know, like straight whiskey or something or Everclear and you know it goes down and it burns, well, that's a clue that it's probably not something that is going to be soothing to your tissues. So alcohol actually does increase inflammation. And sometimes autoimmune issues are just plum genetic and there are environmental factors and other things involved. But you know, we can really help people if, when they have autoimmune issues, whether it's diabetes or not, recognize the importance of emotion regulation and health behaviors. We can help people when they've got depression and anxiety, their mood disorders or ptsd, recognize that those things keep that HPA axis activated, which can contribute to inflammation and potentially development in people who are vulnerable, potentially the development of autoimmune issues. So we can see how these things start being related to one another. Whether we're talking about treatment or intervent or prevention, a lot of the things that we're going to talk about are the same. Hypothyroid can be autoimmune in nature. Thyroid disease interferes with the metabolism and can alter blood sugar, increasing the risk of developing diabetes and making it harder to manage your blood sugar. If you do have diabetes, thyroid disease can be diagnosed, can develop at any point in life. And interestingly, in my mind, I guess one of the more common times that thyroid hypothyroid gets becomes an issue for women is after they give birth. Which, let's think about this. If diabetes is a autoimmune issue and an autoimmune issue can be triggered by excessive stress on the body, think about what happens when somebody gives birth. You know, that Is stress on the body, you know, making another human and then, you know, adjusting to not making that other human. That's a lot of, you know, gyrations for the body to go through. So it makes sense during that period of increased stress and inflammation while the body recovers, that if they are predisposed to autoimmune issues for some reason, they, that that would be a, an interesting window for it to develop. Hyperthyroidism and hypothyroidism are both associated, as I said earlier, with hyperglycemia. Either way. With hypothyroid, well, either way it's altering how the body is handling metabolism and the need for blood sugar. So let's look at these. I did a little chart because I like to do things in charts. How is diabetes related to depression? Well, something we haven't talked about so much. When people are diabetic, especially diabetes type 2, a lot of times they are overweight. People who are overweight and they have excess fat. There are a lot of people who are, you know, power lifters who are technically overweight, but they've got a really low body fat. What we're talking about here is excess fat because excess fat increases estrogen levels. Estrogen increases inflammation in autoimmune diseases. Now I the important thing here is in autoimmune diseases, estrogen in some situations is actually anti inflammatory. But they found in people with autoimmune issues, estrogen actually acts as an inflammatory hormone in a lot of cases. Inflammation, when we have it, we know that systemic inflammation, as is common in autoimmune diseases, increases depression. We know that there is a very strong correlation between systemic inflammation and depressive symptoms. Another relationship. So when people are over fat, they may have increased estrogen which can increase inflammation, make autoimmune issues worse, as well as contribute to depressive symptoms. Hypoglycemia can often lead to depressive symptoms as we saw. So if you have somebody who has pre diabetes, undiagnosed diabetes, or undiagnosed pre diabetes and they frequently have mood, mood swings, you know, it may be important whether they're depressive symptoms or anxiety or irritability symptoms, it's important for them to get screened because those frequent mood swings may be a sign of blood sugar difficulties. Bipolar disorder does not rapidly cycle in an hour or a three hour, you know that it doesn't cycle that quickly. Now there are some issues with cyclothymia and other corresponding anxiety disorders or PTSD where you might see some mood swings throughout the day. But I have never yet in 20 some odd years, worked with anybody with bipolar disorder whose moods cycled, you know, in, in terms of hours. So a lot of people come in and they've self diagnosed because they'll go from being depressed to being really irritable and their, their mood's just all over the place. And, and I'm, I really want to take a better look at that from a physiological as well as from a cognitive and environmental standpoint. And as we mentioned, in type 2 diabetes, as well as depression, serotonin is low. So it's not uncommon for people with type, type 2 diabetes to have concurrent depression. That needs to be addressed. And you know, that can be a biochemical thing, so there's overlap there. If you're working with people who are depressed, they are at higher risk for potentially for diabetes or that may be something that is a physiological contributor to their mood issues. Now, diabetes and autoimmune issues. Most cases of diabetes, with the exception of gestational diabetes and steroid therapy induced diabetes, are autoimmune in nature. So, you know, they kind of are the same thing. Diabetes is most often an autoimmune issue, which increases the risk of other autoimmune issues, including thyroid dysfunction. Now remember that thyroid dysfunction can contribute to the development of autoimmune issues because it alters how the body handles, handles blood glucose, even if it's not, even if it's caused by an iodine deficiency or something, if it's long standing enough. But thyroid dysfunction, hypoglycemia, and hyperglycemia can also produce mood issues, which is why it's so important to have a basic blood panel and a diabetes screening done on everybody. Because if the problem is in the thyroid or with diabetes, then antidepressants may not help the person start feeling better. Talk therapy certainly isn't going to address their thyroid or their blood sugar issues. So let's go down to the next row. Depression and anxiety. How does that relate to diabetes? Well, some people experience depression and anxiety that are related to their health condition. They get the diagnosis and they're like, crap. You know, I saw what happened to my great, great granny or my friend over here, and I'm terrified. You know, I don't want to go blind. I don't want to have an amputation. I don't want to, you know, so we need to help people examine the facts for and against their catastrophic beliefs. You know, what are the facts that would lead you to have blindness with diabetes? Okay, what has to happen for, for you to get to that final catastrophic point, what are the factors within your control that can mitigate or even prevent you from getting to that point? And what is the probability that if you do the things that you're able to do, if you change the things that you can, that you will continue down that path and end up with blindness? So if you get good sleep, have good health behaviors, manage your blood sugar, see your doctor, what are the chances that that catastrophic endpoint is actually going to happen? So it's important to help people examine the facts, find their power in the situation, and really look at the probability that if they do everything that they can, you know, some things are out of their control. How likely is the worst case scenario? So that's huge in health and health anxiety. Hypoglycemia can also produce symptoms of depression and anxiety. So if people are having repeated hypoglycemic episodes and even irritability and anger, they may have, they may present with mood symptoms not recognizing that it's related to their blood sugar. Hypoglycemia doesn't just occur if you haven't eaten for a long, long time. Because a lot of times people will tell me, well, I eat regularly. That's not all there is to it. It's how your body handles the sugar when you've, when you've got it in, in your system and you know insulin levels. Because if, if your body pumps out too much insulin, then your, your blood sugar may drop. So it's important to help people recognize that it's not just about the frequency with which they eat it. It's also about the functioning of the factory that handles that energy. Depression and anxiety increase inflammation, which can worsen autoimmune conditions. So we want to help people address that. Circadian rhythm disruption is associated with blood sugar imbalance as well as mood issues. We know that people are at a greater risk for mood issues when they are sleep deprived or when their circadian rhythms are wonky, when they're waking up, when they don't have that characteristic spike of cortisol and then gradual decline throughout the day, it often contributes to mood issues and further sleep disruption. If they're trying to go to sleep and their cortisol levels are still at 50%, you know, they're going to have a dickens of a time trying to relax. To get their quality sleep, they need to reset the system, basically. And depression and anxiety, how does that relate to autoimmune issues? Systemic inflammation is associated with clinical depression. And we just talked about the fact how most people with Autoimmune issues also have high levels of health anxiety. According to the CDC, approximately 13% of American adults have diabetes diagnosed type 1 or type 2. They've got diabetes and another 35% have pre diabetes. Do the math. That's 48% estimated by the CDC at this point in time have either diabetes or pre diabetes. Which tells you the likelihood that the people on your caseload have diabetes or pre diabetes is pretty dagum high because the people who have diabetes and prediabetes are at higher risk for depression and autoimmune issues and associated, you know, mood issues. So chances are more than 48% of your caseload has diabetes or pre diabetes or some level of blood sugar issues. Diabetes is an autoimmune condition and they're finding now that the research has indicated that even type 2 diabetes has an autoimmune component to it. Autoimmune conditions are caused by inflammation and inflammation and they cause inflammation as well. Inflammation hyper excites the HPA axis. The body says, crap, there is a breakdown in this system down here. We need to go repair it so the body can function well. Well, the way the body repairs is by increasing inflammation. Inflammation and HPA axis over activation are associated with depression and anxiety. All people with depression and anxiety should be evaluated for autoimmune issues, including diabetes. You know, we want to screen if we can't get them to go to the doctor, all right, but we want to at least screen for it in, in, as an ethical, in my, in my opinion, it's an ethical imperative that we screen for these things. Integrative recovery plans should focus on reducing inflammation, regulating the 8 and regulating the HPA access to prevent or mitigate autoimmune issues. Now obviously we aren't going to be prescribing anti inflammatories or anything. We do want to refer to a physician who can help with any existing inflammatory issues, pain issues the person may be having. But we can also help people reduce inflammation by regulating their HPA axis and learning non pharmacological strategies to deal with chronic pain such as guided imagery, stretching, massage. There are a lot of things that we can help people with. They actually have also done a lot of research and it's in the video on the YouTube channel that talks about chronic pain management. There are multiple essential oils that they've actually done placebo controlled double blind studies and found that certain essential oils are associated with a increase in pain tolerance or a reduction of pain perception. However you want to think about it. So that's kind of cool. It may not work for everybody, but if you have a client that's willing to try, it probably can't hurt to have them think about and. And remember, essential oils, you don't have to apply, you don't have to ingest, you just sniff them. So unless they have asthma or some other upper respiratory issue, most of the time working with essential oils is, you know, relatively harmless. So I guess that was the end of my summary. There. There are a lot of things we can do, there are a lot of things we can look for in order to help people who have depression or anxiety who present in clinic with us to evaluate all of the causes of their symptoms and at the very least, screen out anything. So screen out a history or screen out diabetes, screen out autoimmune issues to make sure that we are not missing a fundamental physiological issue that's contributing to HPA axis dysregulation. Are there any questions? I know this stuff is, you know, thankfully a lot of it kind of folded in on itself and it may take a second to kind of weed out and, you know, pull out the little nuggets for clinical practice. But hopefully this increased your awareness that people with diabetes may have mood symptoms that need to be addressed and people with mood symptoms may have diabetes or pre diabetes or blood sugar issues that need to be addressed in order to help that person achieve their highest quality of life. Alrighty, everybody, have a great day and I will see you on Tuesday. If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastce to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allceus.com Sponsor thank you.