Stress management is important for health and well-being, but it may not receive much attention. For those with blood glucose concerns, it may be crucial to de-stress.

The “stress hormone” cortisol is an important link between stress and blood glucose control. Normally, cortisol levels spikes early in the morning and then gradually decline throughout the day. This natural circadian pattern may be disrupted in patients with diabetes.

Cortisol levels may remain elevated during the day in diabetic patients. This state of elevation could have implications for managing blood glucose.

The HPA Axis, Cortisol, and Diabetes

Our body’s response to stress is intertwined with the hypothalamic-pituitary-adrenal (HPA) axis. Both physiological and psychological stressors can activate a cascade of hormone secretion via the HPA axis.

When the sympathetic nervous system is activated, there is a sequence of hormone release through the HPA axis:

• Hypothalamus — releases a corticotropin-releasing hormone (CRH)

• Pituitary gland — this is triggered by the CRH to release the adrenocorticotropin hormone (ACTH)

• Adrenal cortex — this is triggered by the ACTH to release cortisol

Cortisol inhibits the secretion of ACTH and CRH. However, according to several human studies, this negative feedback system may be impaired in type 2 diabetes. This could lead to overactivation of the HPA axis and high cortisol levels. 

One function of cortisol is to raise blood glucose by promoting gluconeogenesis and decreasing insulin secretion. Could a sustained pattern of excess cortisol contribute to chronically high blood glucose among individuals with diabetes?

Diurnal Cortisol and Fasting Blood Glucose

Scientists recently completed a 6-year longitudinal, observational study to determine the relationship between diurnal cortisol levels and fasting blood glucose. Participants in the study were from the Multi-Ethnic Study of Atherosclerosis, which included people with diabetes.

Individuals with diabetes had a higher annual percentage of increased cortisol levels when awakening in the morning, less of a decline in cortisol levels during the day, and higher overall cortisol levels compared to people without diabetes. These patterns were associated with a higher annualized percentage increase in fasting blood glucose in participants with diabetes. 

These findings are supported by previous observational research and suggest that the HPA-axis dysfunction may promote a vicious cycle of cortisol dysregulation and elevated blood glucose. Stress management may be a key to breaking this cycle.

Methods to Help Manage Stress

Several types of stress management techniques have been tested in people with diabetes and may be helpful for stress reduction and blood glucose control. Some potentially useful strategies include:

• Mindfulness-based stress reduction — involves placing awareness on present-moment experiences and letting go of fixating on thoughts of the past or future using meditation

• Progressive muscle relaxation — consists of sequentially tensing and releasing various muscle groups to promote feelings of stress release and relaxation

• Yoga — involves a low-impact, mind-body, stress-relieving approach that may help attenuate the stress cascade of the HPA axis by reducing the perception of stress

• Biofeedback — facilitates stress reduction by helping to monitor physical signs of stress and helping to guide efforts to reduce stress through breathing exercises, which is available on biofeedback apps

By Marsha McCulloch, MS, RDN, LN