Tired of feeling tired

Dr Paula Diab breaks down the various reasons that people living with Type 2 diabetes may constantly feel tired.

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Living with Type 2 diabetes

Living with Type 2 diabetes (T2D) is indeed a challenge. Daily life can also present quite a few challenges. Put them together and you often end up with the perfect storm. Just recently I had a patient come to see me about her diabetes that was out of control by her own admission. She went into great detail about how she wasn’t sleeping well, was constantly tired and all the problems that she was dealing with. Not five minutes into the consultation and I was already exhausted as well!

I heard about the ladies at her work who order cake on a Friday that she is unable to enjoy with them. I heard about her washing machine that had packed up and how she had to hand wash all her clothes until she was able to get the repair company to collect the machine and fix it. Then, I heard about her cat that needed to go to the vet; her brother who was out of work who she was sending daily meals to; her car that needed new tyres and the new pharmacist that wouldn’t give her the correct needles on her script. I was exhausted listening to all these problems and initially wondered what on earth they had to do with her diabetes management.

Her stories had everything to do with her diabetes

Her fatigue was not only a physical fatigue from working hard and not sleeping well coupled with financial stressors, but it was a symptom of a far deeper problem.

Diabetes distress is commonly expressed by people as fatigue and it’s estimated that almost half of people with diabetes will experience it at some stage of their life. Usually, this occurs at the diagnosis of diabetes but can also become a problem at various crossroads on the journey of diabetes or when the stress of life and the stress of diabetes intersect to cause havoc.

Diabetes is a complex condition to manage and requires a high level of patient involvement, affecting all aspects of daily life and including complicated treatment regimens and frequent healthcare visits, not to mention the financial burden of a chronic disease.

Life too, comes with many curve-balls and unexpected challenges and if the correct support isn’t available, the results can be overwhelming. As tired as I was feeling halfway through the consultation, I can only imagine the mental and physical fatigue all these challenges must have been causing the patient.

Understanding fatigue in Type 2 diabetes

This case highlights some of the struggles experienced by people living with diabetes but there is often good reason for fatigue in diabetes that does require further medical investigation and management.

Remembering that T2D is a chronic condition characterised by insulin resistance, where the body’s cells don’t respond effectively to insulin. This leads to elevated blood glucose levels and eventually a decrease in the production of insulin from the pancreas. Multiple, interconnected problems may be the cause of fatigue in someone with diabetes.

Fluctuating blood glucose levels

One of the main factors contributing to fatigue in T2D is the fluctuation of blood glucose levels. When blood glucose levels are too high, the body struggles to efficiently transport glucose into cells for energy production. Conversely, when levels drop too low, the brain and muscles may not receive adequate energy, leading to fatigue.

In addition, the body becomes used to certain blood glucose levels and a significant change (either drop or rise) in these levels can have a significant adverse effect. For example, a person who is used to glucose levels around 10mmol/L may start feeling symptoms of hypoglycaemia at a level of 5mmol/L. They may feel hungry, thirsty, tired and even start shaking. However, someone who is used to levels of 5 – 7mmol/L on a regular basis, may not feel these same symptoms until they reach levels <3.0mmol/L.

Recent research is promoting the maintenance of stable blood glucose levels as being as important as average readings. Whereas we used to aim for an HbA1c < 7%, we are now looking at spending 70% of the day in range and having a co-efficient of variation <36%. What this means is that instead of aiming for a specific target and having varying glucose levels to get you there, rather aim to spend most of the day in range and have as little variation as possible.

Insulin resistance

Insulin resistance, the main underlying pathological cause of T2D, means that the body’s cells don’t respond as effectively to insulin. This can reduce the uptake of glucose by cells, depriving them of a crucial energy source. As a result, you may experience persistent tiredness. If your muscles, don’t receive energy, your body becomes weak. If your brain cells lack energy, they too become slow and fatigued.

Chronic inflammation

Exciting new data has shown the association of T2D with chronic low-grade inflammation and immune dysregulation. The constant activation of the immune system and inflammation are certainly factors which can contribute to feelings of tiredness.

Compromised sleep quality

Sleep and diabetes often form a proverbial vicious cycle of problems. Uncontrolled glucose levels can keep you from a sound night’s sleep, which in turn can raise cortisol levels and further increase glucose levels. Associated conditions, such as sleep apnoea and restless leg syndrome, can also cause sleep interruption.

Poor sleep can contribute to daytime fatigue, creating a cycle that perpetuates tiredness.

Sleeping tablets can assist in the short-term to induce a good pattern of sleep but generally, the underlying cause should be addressed rather than relying on long-term sedative medications.

Co-existing conditions

Some people with T2D often have other health conditions, such as hypertension and cardiovascular disease, which can independently contribute to fatigue. The cumulative burden of managing multiple health conditions can take a toll on energy levels. These need to be actively managed and optimised so as to reduce the burden of complications.

Mental health factors

The emotional and psychological impact of living with a chronic condition like T2D can’t be overlooked. Stress, anxiety, and depression are common companions of diabetes and can contribute to feelings of fatigue. These conditions need careful and sensitive management and shouldn’t be tagged as an add-on to an already complicated diabetes consult. Chronic medication may be indicated but usually works best in conjunction with regular psychotherapy and lifestyle intervention.

Managing fatigue in Type 2 diabetes

As with most aspects of diabetes, addressing fatigue requires a holistic approach that considers both lifestyle modifications and medical interventions:

• Blood glucose management

Regular monitoring and management of blood glucose levels are fundamental. Unfortunately, these behaviours form the cornerstone of any management plan in diabetes and can’t be avoided. Incorporating a well-balanced diet, regular physical activity and remaining adherent to medication is vitally important. Monitoring of blood glucose levels and ensuring levels remain as stable as possible will contribute greatly to lessening feelings of fatigue.

• Physical activity

Not only does regular exercise release hormones in the brain that combat fatigue, but it also provides a physical release of energy and improves insulin sensitivity. Blood glucose levels become more regulated, energy levels are enhanced, and a more restful sleep occurs when the body is physically tired.

• Healthy diet

The importance of a well-balanced diet is crucial. Choose foods that are rich in fibre, organic nutrients and low-GI carbohydrates where possible. Lower GI carbohydrates (oat/bran cereals, pasta, sourdough bread) will release energy over a longer period of time and prevent the spikes in glucose levels that occur with higher GI foods (processed cereals, white rice, white bread, etc).

The addition of fat and protein in the correct quantities as well as a good serving of fresh vegetables can also have an extremely beneficial effect on drawing out metabolism and keeping glucose levels more stable.

Opt for fresh, home-grown and unprocessed foods. Get rid of junk food completely; just throw it out. Reduce snacks as much as possible and sit down and enjoy your meals if possible.

Regular, planned meals rather than a daily binge and snack-attack as soon as you return home in the evenings go a long way to improving glycaemic control and preventing the glucose surges that cause fatigue.

• Adequate sleep

Prioritising good sleep hygiene is essential for managing fatigue. Establish a consistent sleep routine, create a comfortable sleep environment, and address sleep disorders with the guidance of healthcare professionals who are specifically trained.

Don’t rely on sleeping tablets in the long-term unless absolutely necessary. Treat the underlying cause, whether it’s getting the correct device to combat sleep apnoea, finding the right medication for neuropathic pains or simply gaining better glucose control.

• Stress management

This is probably the most difficult factor to manage. Life is stressful and there is no getting away from it. Chronic stress can exacerbate fatigue and impact blood glucose levels. But try to find the time to investigate a suitable technique that works for you; it may be mindfulness, meditation or relaxation exercises. Perhaps it’s just connecting with friends, spending time nurturing your spiritual self or dedicating time each day to unwind and disconnect.

Conclusion

Fatigue in Type 2 diabetes is a multi-faceted issue involving physiological and psychological factors. Perhaps in understanding the mechanisms behind this single symptom, people with T2D will feel empowered to start addressing some of the concerns and seek adequate help.

It’s impossible for a diabetologist to pay the vet bill, fix the washing machine, repair the car tyres and argue with the pharmacist about which needles are required and why. However, it’s completely possible to lend a listening ear.

Breaking down some of the stressors, identifying which need urgent attention and which can be side-lined can be very helpful strategies. If fatigue is due to any of the diabetes-related scenarios discussed above, then treating the root cause of the problem is going to give the best outcome.

However, if fatigue is more related to be a symptom of diabetes distress, then compounding the problem with additional demands of tight glycaemic control is not going to help.

Sometimes, these curveballs do all arrive at the same time. I often use the analogy of a juggler with too many balls in the air. A good suggestion is to concentrate on just a few important balls, allow some to drop and pick them up when you can. Concentrate on self-care first and get the basics right. Utilise the skills of the entire diabetes team and seek appropriate help where needed.

Diabetes isn’t a disease that can be treated with a bi-annual 15-minute visit to renew a script. A comprehensive approach that includes blood glucose management, lifestyle modifications, and emotional well-being is essential for improving overall quality of life. And if digesting all of that does make you feel tired…at least you know you’re not alone.

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