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Maintenance of glucose control in patients with type 1 diabetesduring acute mental stress by riding high-speed rollercoasters

Wiesli, P; Krayenbühl, P A; Kerwer, O; Seifert, B; Schmid, C

Wiesli, P; Krayenbühl, P A; Kerwer, O; Seifert, B; Schmid, C (2007). Maintenance of glucose control in patientswith type 1 diabetes during acute mental stress by riding high-speed rollercoasters. Diabetes Care, 30(6):1599-1601.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Diabetes Care 2007, 30(6):1599-1601.

Wiesli, P; Krayenbühl, P A; Kerwer, O; Seifert, B; Schmid, C (2007). Maintenance of glucose control in patientswith type 1 diabetes during acute mental stress by riding high-speed rollercoasters. Diabetes Care, 30(6):1599-1601.Postprint available at:http://www.zora.uzh.ch

Posted at the Zurich Open Repository and Archive, University of Zurich.http://www.zora.uzh.ch

Originally published at:Diabetes Care 2007, 30(6):1599-1601.

Maintenance of glucose control in patients with type 1 diabetesduring acute mental stress by riding high-speed rollercoasters

Abstract

Patients with diabetes and health care providers are often confronted with questions concerningpsychological stress as a possible reason for glucose excursions; chronic psychosocial stress has beenassociated with higher levels of A1C and poor adherence to treatment (1,2). Few studies have addressedthe effect of acute psychological stress on glucose concentrations in patients with type 1 diabetes,showing no or only minor effects, such as an increase in insulin resistance and slightly delayeddecreases in glucose concentrations following moderate stress in the postprandial period (3-5). Sincemany patients and caregivers have challenged this view, we asked patients with type 1 diabetes tomonitor glucose concentrations during a strongly stressing experiment.

Maintenance of Glucose Control in PatientsWith Type 1 Diabetes During Acute MentalStress by Riding High-Speed RollercoastersPETER WIESLI, MD

1,2

PIERRE-ALEXANDRE KRAYENBUHL, MD3

ORANNA KERWER1

BURKHARDT SEIFERT, PHD4

CHRISTOPH SCHMID, MD1

P atients with diabetes and healthcare providers are often con-fronted with questions concerning

psychological stress as a possible reasonfor glucose excursions; chronic psycho-social stress has been associated withhigher levels of A1C and poor adher-ence to treatment (1,2). Few studieshave addressed the effect of acute psy-chological stress on glucose concentra-tions in patients with type 1 diabetes,showing no or only minor effects, suchas an increase in insulin resistance andslightly delayed decreases in glucoseconcentrations following moderatestress in the postprandial period (3–5).Since many patients and caregivers havechallenged this view, we asked patientswith type 1 diabetes to monitor glucoseconcentrations during a strongly stress-ing experiment.

RESEARCH DESIGN ANDMETHODS — A total of 20 patientswith type 1 diabetes (all on intensified in-sulin treatment) were recruited from a re-cent study investigating the effect of acutemoderate psychosocial stress on glucoseconcentrations (5). Patients were exposedto acute mental stress by riding on twodifferent rollercoasters within 15 min.The first rollercoaster was a steel coasterstarting from a height of 240 feet andreaching a speed of 79 mph with four pos-itive Gs and the second an indoor coasterin absolute darkness. Blood pressure (by

an ambulatory blood pressure monitoringdevice), heart rate (by 24-h electrocardio-gram), and salivary cortisol were moni-tored during a preceding control daywithout stress application and on thestress testing day. Glucose concentrationswere monitored in 5-min intervals by theMedtronic MiniMed continuous glucosemonitoring system (CGMS). Capillaryblood glucose concentrations were deter-mined in 15- to 30-min intervals by re-flectance meter (results not shown,consistent with CGMS data). A total of 10patients performed the rides in the fastingstate. Patients were allowed to drink waterand injected their basal insulin as usual.An additional 10 patients were riding therollercoasters 75 min after intake of astandard meal containing 50 g carbohy-drates (with the same prandial insulindose on both days). The rides were per-formed between 1:00 and 3:00 P.M. Theprotocol was approved by the ethics com-mittee of the University Hospital of Zu-rich; all patients gave written informedconsent.

RESULTS — Mean � SD age of 20 pa-tients (8 female) with type 1 diabetes was37 � 11 years, diabetes duration 14 � 10years, BMI 24.7 � 4.5 kg/m2, and A1C7.6 � 0.9%. Blood pressure, heart rate,and salivary cortisol remained stable forthe observed period during the controlday. During the rides, heart rate rose from82 � 7 bpm at baseline up to a maximum

of 158 � 16 bpm (P � 0.001). Bloodpressure increased from 124/79 � 12/9 to160/96 � 17/14 mmHg between the tworides (P � 0.001). Salivary cortisol in-creased from 6.3 nmol/l (range 2.8–11.4)to a maximum of 19.3 nmol/l (5.6–49.3)60 min following the ride (P � 0.008).Glucose concentrations of 10 patients in-vestigated in the fasting state remainedfairly stable, both during the control andstress testing day (Figure 1A). At the timeof stress application, glucose concentra-tions were 6.2 � 1.6 mmol/l on controland 6.7 � 2.3 mmol/l on stress testingday (P � NS). A two-factor repeated-measures ANOVA showed no significantdifferences in glucose concentrations be-tween the control and stress days. Tenpatients were investigated in the post-prandial state (Fig. 1B). Baseline glucoseconcentrations before the intake of themeal on control and intervention dayswere 7.2 � 2.2 and 6.6 � 2.4 mmol/l(P � NS), respectively. Glucose concen-trations increased comparably in re-sponse to the meal, by 3.7 � 2.6 mmol/lon the control day and by 3.3 � 2.0mmol/l on the stress testing day, and re-turned to baseline within 3 h after themeal on both days. There appeared to bean attenuated increase in postprandialglucose concentrations during the 30 minbefore the ride. However, a two-factor re-peated-measures ANOVA revealed nosignificant difference of glucose concen-trations between the control and stressdays.

CONCLUSIONS — We found that se-vere short-lived mental stress, as docu-mented by markedly increased heart rateand blood pressure (reflecting sympatheticactivation) and salivary cortisol, barely af-fected glucose control in patients with type1 diabetes, consistent with previous reportsinvestigating the effect of moderate mentalstress on glucose control (3–5). The main-tenance of glucose control (as shown in Fig.1 only by interstitial but confirmed by lessfrequent capillary readings) is all the moreremarkable since patients with type 1 dia-betes are unable to adapt insulin secretion.Our patients (type 1 diabetes duration 14years, mean age at diagnosis of diabetes 21

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From the 1Department of Internal Medicine, Division of Endocrinology and Diabetes, University Hospital ofZurich, Zurich, Switzerland; 2Medizinische Klinik, Endokrinologie und Diabetologie Kantonsspilal Frauen-feld, Frauenfeld, Switzerland; the 3Department of Internal Medicine, Medical Policlinic, University Hospitalof Zurich, Zurich, Switzerland; and 4Department of Biostatistics, University of Zurich, Zurich, Switzerland.

Address correspondence and reprint requests to Peter Wiesli, MD, Kantonsspital Frauenfeld, Mediz-inische Klinik, Endokrinologie und Diabetologie, Frauenfeld, Switzerland. E-mail: peter.wiesli@stgag.ch.

Received for publication 11 October 2006 and accepted in revised form 21 February 2007.Published ahead of print at http://care.diabetesjournals.org on 2 March 2007. DOI: 10.2337/dc06-2102.Abbreviations: CGMS, continuous glucose monitoring system.A table elsewhere in this issue shows conventional and Systeme International (SI) units and conversion

factors for many substances.© 2007 by the American Diabetes Association.The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby

marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

E p i d e m i o l o g y / H e a l t h S e r v i c e s / P s y c h o s o c i a l R e s e a r c hB R I E F R E P O R T

DIABETES CARE, VOLUME 30, NUMBER 6, JUNE 2007 1599

years) were unlikely to have relevant resid-ual insulin secretion and were on a fixedinsulin dose when they faced a challenge,

resulting in an upregulation of insulin-counterregulatory hormones. The lattermay contribute to an excellent matching of

glucose fluxes (appearance and disappear-ance) so that glucose homeostasis duringacute mental stress can be maintained.However, our study was carried out withpatients in reasonable metabolic controland cannot necessarily be extrapolated tothe many patients who face mental stresswith poor glycemic control or have chronicmental stress.

In the fasting state, glucose concen-trations tended to decrease during thecontrol day and remained stable duringand following the rides. Thus, a minoreffect of mental stress on glucose controlcannot be excluded definitively, but it ap-pears that acute short-term mental stressin the fasting state is hardly responsiblefor clinically relevant glucose excursions.Following the intake of a meal, the in-crease of glucose concentrations on stresstesting day was slightly attenuated, andglucose concentrations tended to remainlower throughout the experiment. The at-tenuation of the rise in postprandial glu-cose concentrations failed to reachsignificance and was noticed 30 min be-fore the rides (i.e., when patients were an-ticipating the rides) and is possiblyexplained by increased utilization of glu-cose by the brain, heart, or respiratorymuscles (i.e., by tissues in which the ac-tivity is markedly increased in response tostress). Following the ride, the differencein glucose concentrations between thestress and control days became smaller,and almost identical glucose values wereobserved 3 h after the meal.

In conclusion, most patients withtype 1 diabetes exposed to strong short-lived mental stress (i.e., riding on roller-coasters) can keep good glycemic controlwithout adjusting the insulin dose.

Acknowledgments— The study was finan-cially supported by an unrestricted grant ofRoche-Disetronic Switzerland.

We thank Dagmar Holm and MonikaVoggenreiter for analyzing the blood pres-sure data, Clemens Kirschbaum for cortisolanalysis, and Frank Enselait for analyzingthe electrocardiograms.

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Figure 1—Glucose concentrations measured by CGMS on the control day without stress (circles)and on the stress testing day (squares) in 20 patients with type 1 diabetes. In total, 10 patients wereriding the rollercoasters in the fasting state (A) and 10 patients after intake of a standard meal at�75 min (B). The ride on the first rollercoaster started at time 0 and the ride on the secondrollercoaster at time 10 min. Glucose concentrations are shown as change from baseline values(difference from the glucose value at time �45 min in fasting patients and from the glucose valueat time �105 min in patients taking a standard meal at �75 min). A two-factor repeated-measures ANOVA revealed no significant difference of glucose concentrations between control andstress testing days, neither in the fasting nor postprandial state.

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Wiesli and Associates

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